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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 ^ERMIT Permit No. Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued H <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const: <br /> and/or install the work herein described. This application is made in compliance with Sar <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joa(,uin Local Health D <br /> ��• ' � ,��c� F ,�.��� CENSUS TRACT <br /> IV <br /> JOB ADDRESS/LOCATION l`_,�.�.•�/ � D.i. <br /> Owner's Natie Phone-> L ef-S-D <br /> ,Address / , i"��C-C.c�� City G� ��- -�-i-- <br /> n per. <br /> Contractor's Name �1 �� it ACI- License //G.L3�.3 Phone3 <br /> TYPE OF WORK (Check) : NEW WELL L7 DEEPEN RECONDITION L7 DESTRUCTION Er <br /> PUMP INSTALLATIONJ PUMP REPAIR /-7 PUMP REPLACEMENT /=T <br /> Other L/ <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 /> IMPENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /.2 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Donestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Inf ormation,74a, <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /-7 State Work Done <br /> DESTRUCTION 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 Die <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN <br /> after ccmpletion of my work ort a new well, I will furnish the San Joaquin Local Health Die <br /> WELL DRILLERS RETORT of the well and notify them before putting the well in use. The abov <br /> Information 4 true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPE <br /> PRIOR TO GRjPLV.tLNG ANR A FINAL INSPECTION. <br /> SIGNED TITLE - 2 <br /> ,DRAW PLOT PLAN ON REVERSE S IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r� <br /> DATE <br /> APPLICATION ACCEPTED BY -- `-� <br /> AnnTTTnW AT rn%fMVVTC• J "I <br />