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SAN JOAQUIN .LOCAL" HEALTH DISTRICT WW �) <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �1 <br /> Telephone:. (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ—? <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 /> County Ordinance. No: 1862 acid the Rifles and 'Regulations of.the San Joaquin. Local Health District. <br /> CENStTS .TRACT <br /> .705 ADDRESS/LOCATION <br /> Owner's Name Phone <br /> Address ,. - Cityos_c� i <br /> Contractor's Name License hone4� __ . <br /> 5J4 <br /> TYPE OF WORK (Check) : NEW WELL jP/_DEFtPEN /_7 RECONDITION / 1 DESTRUCTION /7 <br /> PUMP INSTALLATION I PUMP REPAIR J J PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC 'TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISP0 AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC: WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE a WELL CONSTRUCTION SPECIFICATION <br /> Industrial Cable Tool Ilia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 46 _____ ; <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 --- <br /> Geophysical _ Suvface Seal Installed B <br /> :PUMP INSTALLATION: Contractor 5144 <br /> Type of Pump r H.P. <br /> PLT>e REPLACEMENT: J State Work Done <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 District <br /> and the State of California;lpertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after" completion of my wortC*on a new well, Z will furnish the San Joaquin Local Health District a <br /> WELL,,,DRILLER.S REPORT of the well and"notify theiu'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 GROUT IAC AND A FINAI. INSP CT ION, ,SIGNED '1;4TAtL <br /> (DRAW PLOT-PLAN-ON--REVERSE SI <br /> FPR DEPARTMENT USE ONLY <br /> ( PHASE I <br /> ?LICATION ACCEPTED BY �7� DATE ✓/ �-� <br /> __-,DITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE Z /ETNA INSPECTION <br /> pECTION BYDAfiE /1- / - 7 INSPECTIO&, BY. DATE <br /> I <br /> 7 <br />