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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE 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 Aereby 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 th Rules and Regulations of the San Joggpin Local Health Dietric <br /> y 5 t tt.) . ;�9 anter -� <br /> JOB ADDRESS //14, <br /> /� M�/� e • MI: � 49:6Vf ® CENSUS TRACT <br /> Owner's Name 14, J, Vim" *;L Mnot5w, A. Phone <br /> Address 4-e0.z. GAS ' C�13_ 1?b'-[0 City ' <br /> Contractor's Name Tlko kky &Agejy0-0!!� License 1�I� Phon <br /> —� n +s'J' 4"-6/ <br /> TYPE OF WORK (Check) : NEW WELL —DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR /—/—PUMP REPLACEMENT /–J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER• & �0�#../ <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 9 A' <br /> Domestic/public Driven Gauge of Casing 1a0114 <br /> Irrigation Gravel Pack Depth of Grout SealSpm v< ~C4 <br /> Cathodic 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. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: L/ 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 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 /> PRIOR TO NG AND A FINAL INSPECTION. }�, <br /> SIGNED R . ,� TITLEay, Ak:;& <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I q ,(� <br /> APPLICATION ACCEPTED BY ' DATE S'//- 7U <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 1 <br />