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(_�d JOAQUIN LOCAL HEALTH DISTRIC1,111 <br /> ` FOE USE: 1601 E. Hazelton Ave. , ',Stockton, Calli. <br /> Telephone: (209) 466-6781 p <br /> t o <br /> zl; APPLICATION FOR WELL CONSTRUCTION OR PUMP PERC emi . 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '�•, <br /> Y2,` , (Complete In Triplicate) <br /> `• '.;A tion 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 Joaquir <br /> :County Ordinance No. 1862 and the- Rules and Regulations of the San Joaquin Local Health District. <br /> :JOB ADDRESS/LQCATIQN`iY72 w CENSUS TRACT <br /> F <br /> Owner's Name Phone 3697 S3� <br /> %Address y`� City <br /> Contractor's Name License �fQ2U Phone <br /> •'TYPE OF WORK' (Check) : NEW WELLf�f DEEPEN /_/ RECONDITION /__7 DESTRUCTION /7 <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 'f Industrial -Cable Tool Dia, of Well Excavation <br /> Domestic/private,' Drilled Dia. of Well Casing _ N <br /> Domestic/public Driven Gauge of Casing <br /> s irrigation Gravel Pack Depth of Grout <br /> �! Cathodic ProtectionRotary 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 /> k' <br /> PUMP .REPAIR: /�/ 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 bistrict <br /> ;';and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> kafter completion of my -work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting-the-well in use. The above <br /> jnformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AN A FINAL INSPECTION. <br /> :'SIGNED TITLE <br /> �''; <br /> 6t r (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> VlPHASE I <br /> APPLICATION ACCEPTED BY - L� DATE <br /> 'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> 1�_ <br /> F N 1 G? 1177 2M <br /> Fi too.. 7I. � ., . <br />