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j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., -L23 ji <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued) 2 <br /> (Complete In. Triplicate) 6: <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 es nd Regulations of the San Joaquin Local' Health District,.; ' <br /> JOB ADDRESS/LOCA N CENSUS- TRACT <br /> Owner s 'Name �. ��- Phoneme <br /> Address / <br /> City " <br /> Contractor's Name eT '� � � s License #`3,)-a7_$hone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN /7 RECONDITION /-7 DESTRUCTION' %j <br /> PUMP INSTALLATION _Z/ PUMP REPAIR/-7 PUMP REPLACEMENT <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 ther Information ...._ <br /> Geophysical &'Surface. Seal Ins abed B i <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Dane <br /> i <br /> PUMP .REPAIR: %/ State Work Done <br /> UE&TRUCTION OF -WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Thereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction.. Within FIFTEEN DAYS <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 best of- my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F9A&EPARTMEN7 USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED¢ ` <br /> DATE �5 .b <br /> ADDITIONAL COMMENTS: <br /> PHASE .1I GRAUT'INSPECTION PHASE III FINAL INSPE IO <br /> INSPECTION BY DATE INSPECTION BY 44 c ' DATE <br /> 3v U IZ13A n_" ,_-7� 1.ham' ever <br />