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SAN JO Q <br /> A UIN LOCAL HEALTH DISTRICT <br /> 'OF:,OFFICE USE: " 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 # <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , <br /> ,. (Complete In Triplicate) <br /> . Application is hereby 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 Joaquin' <br /> Co ,nOrdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION �z ! c I,1z S r? CENSUS TRACT ' <br /> A-A/l <br /> Owner'g Name J`IJ 1, C' i AQ a ) ✓)_�� J )v� _ Phone <br /> Address I` City.'S 70 G'r a <br /> Contra ctoar l a Name C,0, License #7 0. Phone AleZ-f`l7 <br />. r <br /> TYPE"OF WORK (Check): NEW WELL /7 . DEEPEN,.�T~ RECONDITION'/7` DESTRUCTION f7 <br /> PUMP INSTALLATION,/ PUMP REPAIR 1_7PUMP REPLACEMENT 17 <br /> Other /% <br />'i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. . � .PIYNPRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC* WELL- PUBLIC DOMESTIC WELL <br /> INTENDED USE y TYPE ,OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ry " : 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 ProtectYion Rotary Type of Grout <br /> Disposal ; Other Other Information � <br /> Geophysical-.. Surface Seal Installed B : <br /> 3PUNP INSTALLATION: Co tractor <br /> T..ype>of Pump H.P. <br /> PUMP REPLACEMENT: . / 1 State Work Done <br /> PUt��.REPAIR: -/7 :State Work Done <br /> DESTRUCTION OF WELL: - -Well Diameter Approximate Depth <br /> i - Describe Material and Procedure <br /> i 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 mq.work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT .of the 'weli 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 GROAT INSPECTION <br /> PRIOR TO G OUTI G AN A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /f F <br /> APPLICATION' ACCEPTED BY �;c�% DATE / <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE - <br /> 17 iI IA7f. va.. 7_7A ' <br />