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SAN `JOAQUIN LOCAL HEALTH DISTRICT <br /> EFO�R76FFYE 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 Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations <br /> of <br /> the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION S-302- JE. Wo&Se CENSUS TRACT <br /> Owner's Name E�. . f QQn _ Phone '5�y-f-;bg <br /> Address ,�'c3 D T /� l $�- �iQ�, Ci. <br /> Contractor's Name I License II 4�0Z Phone <br /> 01 z'- <br /> TYPE <br /> ;TYPE OF WORK (Check) : NEW WELL /;�EEPEN `/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / 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�2 PUBLIC DOMESTIC WELL' <br /> INTENDED -USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _____,4ndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> —!� Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge of, Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal <br /> Cpthodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PU 2d REPAIR: / / State Work Done <br /> T <br /> PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to a est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU D INSPECT—ION. <br /> SIGNED - TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1 ¢� <br /> ADDITIONAL COMMENTS: We 41 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY e114 DATE / INSPECTION BY DATE �1 <br />