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__ - `N JOAQUIN LOCAL HEALTH DISTRICT <br /> O OFFICE USE: 16LI%wE. Hazelton Ave. , Stockton, Ca,.. c. �J <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 Il ay�7 <br /> (Complete In Triplicate) <br /> -pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .nd/or install the work herein described. This application is made in compliance with San Joaqui <br /> .ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION N 3 ��f Si 5 CENSUS TRACT <br /> wner's Name : (j! �C - Phone `�-2-f - <br /> ddress City <br /> ontractor's Name License # Phone <br /> YPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> ,ISTANCE TO NEAREST: SEPTIC TANK /.,2_S-' SEWER LINES 12, - PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELh <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private _ Drilled Dia. of Well Casing L <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 /> UMP INSTALLATION: Contractor ' <br /> c.V N <br /> Type of Pump �_� --- ---- - H.P . <br /> 'UMP REPLACEMENT: / / state Work Done <br /> 'UMP REPAIR: / / State Work Done _ <br /> )6STRUCTION 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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTING AND .4 FINAL. INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I DATE //'� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTICI� PHASE,;V/FINAJ, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �.���( DATE - 7 7 <br /> 011 <br /> , _ <br />