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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> YOE�OVFICE USE: 1601 E. Hazelton Ave. ,,.-,Stockton, Calif. <br /> Telephone: (209)"-466-6781- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued a-- <br /> (Complete In Triplicate) <br /> Application is hereby made totheSun 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. 1862a'nd =the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 11i�j � � CENSUS TRACT <br /> Owner's Name Phone , <br /> - <br /> e <br /> Address ` b�� �/ City! . . . <br /> d <br /> Contractor License #�t�-,iY Phone A) <br /> :s Name' '�� <br /> TYPE OF WORK (Check) : NEW WELL -/7 DEEPEN /7 RECONDITION fT DESTRUCTION f7 <br /> PUMP INSTALLATION/PUMP REPAIR/_7 PUMP REPLACEMENT 17 <br /> Other <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 v <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 " <br /> Geophysical t Surface Seal Installed 'B : a <br /> s <br /> C <br /> PUMP. INSTALLATION: Contractor <br /> r <br /> Type of Pump z..._ r H.P. '_ s � <br /> PUMP REPLACEMENT: / / State'- Work Done ' <br /> 'PUMP .REPAIR: / /, State Work Done <br /> DES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and'FProcedure <br /> C <br /> 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 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 /> information is true ,to the best.of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />, PRIOR TO GROUTI D A FI_NALTYSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> f ADDITIONAL COMMENTS: 1-441 <br /> PHASE It GROUT INSPECTION P E III/FaRAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - E " : <br /> P. H YLM Vo%, 7..7L. --- <br />