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_ °-N JOAQUIN LOCAL HEALTH DISTRICT ,1 �1 <br /> FOF OFFICE CSE_: 160 . Hazelton Ave. , Stockton, Ca, <br /> Telephone : (209) 466--6781 / l <br /> I—r 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 /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Tend/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> _OB ADDRESS/LOCATION CENSUS TRACT <br /> weer's Name L1111�J� ti L t1L (!�� <br /> Phone 33L,62 6) <br /> Address 9:2 qG( City <br /> intractor's Name �A�,Dn A Licensec t L Phone <br /> YPE OF WORK (Check) : NEW WELL X DEEPEN / / RECONDITION /T/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> _ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER " r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL t <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 /> X Irrigation Gravel Pack Depth of Grout Seal <- _ <br /> Cathodic Protection Rotary Type of Grout A/ , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By_: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> "UMP REPLACEMENT: / / State Work Done <br /> IYUMP REPAIR: / / State Work Done <br /> aS.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd 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 a <br /> "ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> reformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> FRIOR TO G OUTING AND A FINAL INSPECTION. A <br /> SIGNED Q n- TITLE : <br /> -ZtL::!hA/2_ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> y FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PPLICATION ACCEPTED BY G DATE <br /> -mDDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY ;: DATE <br /> 0,177 7M <br />