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i <br /> C/L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County _Ordinance No._1862. and the Rules and Regulations of the San Joaquin Local Health District. 1 <br /> JOB ADDRESS/LOCATION f __A _ "`CENSUS TRACT -1011- 1-?C)-(k <br /> Owner's Name Phone <br /> r• <br /> Addressa. City 1 <br /> Contractoz's Name 7-7 <br /> License �� J Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /__7/­DESTRUCTION /7 r <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE' TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> IN ED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ndustriala le Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of iWell Casting ` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ^ ' <br /> Geophysical Surface Seal. Installed By: <br /> R J 7 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> -P'UMP .REPAIR: - / / State Work Done. <br /> DES-TRUCTION_ OF WELL: Well Diameter Approximate Depth <br /> —� <br /> Describe Material and Procedure , <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAIS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information is true to the st of my knowledge and belief. I WILL C FOR A 'GROUT INSPECTION <br /> PRIOR TO GR96ING AN- A FjW IN CTION. <br /> SIGNED TITLE r <br /> (DjkAW PLOT PLAN ON REVERSE SIDE) <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 6 0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> j INSPECTION BY DATE INSPECTION BY f, DATE 9 z <br /> 2M <br />