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P T Y <br /> SP JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OF OFFICE USE:, Vhf 1603. Hazelton Ave. , Stockton, Cali <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> plication is 'hereby made to the San Joaquin Local Health District for a permit to construct <br /> .d/or install the work herein described. This application is made in compliance with San Joaquin <br /> -unty Ordinance No 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> B ADDRESS/LOCATION //Z tj CENSUS TRACT <br /> 4 <br /> -- - - P Phone <br /> ner s Name �_ , <br /> dress d <br /> ntractor s Name �O License �� a9Q�� Phone J32./09 <br /> Phone <br /> i <br /> PE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DQHFSTIC 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 <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 CJ <br /> "Geophysical Surface Seal Installed By: <br /> AP INSTALLATION: Contractor <br /> H.P. <br /> ,..-Type of Pump <br /> -MP REPLACEMENT: � / / ` State Work Done <br /> ;°MP -.REPAIR: ,/ State Woxk D ne <br /> S1-TRUCTION OF WELL: We11 Diame er �2.r�� Approximate Depth <br /> Destr be Material and Procedure $ Z%T— /L/ <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local He lth District <br /> id the State of California pertaining to or regulating wellconstruction. Within FIFTEEN DAYS <br /> :ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ,LL DRILLERS REPORT of 'the well and notify them before putting the wellin use. The above <br /> iformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> I.OR TO ROUTING AND A FINAL INSPECTION. <br /> ` TITLE <br /> GNED [ � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ON <br /> !.ASE I <br /> 'PLICATION ACCEPTED BY -: DA'IE..,,_.....r.,.., ,. <br /> DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE /FIN INSPECTION <br /> ;SPECTIf�N BY DATE 3 INSPECTION BY DATE $_ ;_7 <br />