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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB�OFPICB U E: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.r-l- O6. <br /> THIS PERMIT EEPIRES 1 YEAR FROM DATE ISSUED Date Issued/,2-�. <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Lv Al Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joe< <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dietria <br /> JOB ADDRESS/LOCATION �WANI 12f CENSUS TRACT <br /> Owner's Name �r11' /// 7Phone <br /> Address _ /.3 a0 // /)/D.e�r�lLy /City S'i��!/�-„ <br /> Contractor's Name NO,2l / 2s SHG License Q.'&y Jf¢Yhone <br /> TYPE OF WORE (Check): NEW WELL /-7 DEEPEN /7 RECONDITION >< DESTRUCTION % <br /> PUN? INSTALLATION L7 PUMP REPAIR PUMP PLACEHENT / <br /> Other Az /t /a <br /> DISTANCe TDNEAREST: 9EYTIC TANK SEWER LINES PIT PRIVY <br /> %SHAGS DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLZC DOMES IC WELL <br /> INTBNDED USE TYPS OP WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Die. of Well Excavation <br /> __Domestic/private _Drilled Dia. of Well Casing <br /> _—Irrigate/public _Driven Gauge of Casing <br /> Irrigation P _ Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection _ Rotary Type of Grout IQl_ <br /> _Geophysiosal _Other Other Ivformatlon ✓ ,t <br /> _Geophysical Surface Seal Iwtelled Bv: 1 /�yQ <br /> PUMP INSTALLATIONz Contractor v <br /> Type of Pump H.P. <br /> PUNP REPLACEMENT: L7 State Work Done <br /> PUMP'.REPAIE: L7 State Work Done _ I , 1( y <br /> Diameter <br /> pES RRDGTION OP WBLL: Well emeter Approximate Depth <br /> W r//�S//^ <br /> Well ibMateriel and Procedure <br /> I hereby agree to comply with all lana and regulations of the San Joaquin Local Bealth District <br /> and the State of California pertaining new,w to or regulating well construction.weal <br /> He lth District DAYS <br /> after completion of mY work w a new,well, I will before <br /> furnish the San Joaquin Local AeMe above et <br /> WELL DRILLERS REPORT he well and notify them before putting.WILL <br /> CALL <br /> O we. The above <br /> informative ie [r fo the beat EP my knowledge and belief. I WILL CALL POR A GROUT INSPECTION <br /> PRIOR TO CROU � -1NO.A.FfNB IN SCI;6; <br /> SIGNED W PIgT PLAN ON REVERSE SIDE <br /> ME <br /> PHASE I <br /> FUR ARTNT USE ONLY (� <br /> UJ <br /> APPLICATION ACCEPTED BY DBP <br /> / DATE/ <br /> ADDITIONAL CONI!NTS; <br /> PHASE II GROUT INSPECTION PHASE II PIN Pe ION <br /> INSPECTION BY DATE INSPECTION BY DATE )S— <br />