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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF-4CE' M: 1601 E. Hazelton Ave. , Stockton, Calif:-' <br /> - Telephone : (209) 466-6781 No. <br /> , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP �RMrt eYm ,t D <br /> THISIPERMIT EXPIRES I YEAR FROM.:DATL ISSUED Date Issued �g <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construe.t <br /> and/or install the work hereinidescribed. This application is made in compliance with San Jo € <br /> County Ordinance No. 1.862 and the Rules. and Regulataons. of the San Joaquin Local Health Distrix. <br /> Of <br /> JOB ADDRESS/LOCATION " . led #. NSUS TRACT <br /> Owner's Name Phone "74 <br /> Address - . City . <br /> Contractors Name4 ,� w . l �V <br /> License # /Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /—/ DESTRUCTION /- <br /> PUMP,INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD /apa CESSPOOL/SEEPAGE PIT OTHER&d)&�W--�� i <br /> PROPERTY'- LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial 1 Cable Tool f Dia. of Well Excavation <br />_Z Domestic/private ! Drilled Dia. of Well Casing -- --- <br /> Domestic/public 1 Driven Gauge of Casing <br /> f160 aezL— <br /> Irrigation 1 it/ Grave 1j,ack Depth of Grout Seal <br /> Cathodic Protection I IZ Rotary Type 'of Grout q' <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By : + <br /> PUMP INSTALLATION: Contractor 0� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / J State Work Done <br /> D.ESTRUCTION _OF WELL: Well Diameter Approximate Depth _ r � <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 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 <br /> WEEL 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 GRO ING AND A FL.�2SPECTIO311 <br /> SIGNED TITLE _ �Of <br /> (DRAB LOT PLAN ON RE SE SIDE) <br /> FOR DEPARTMENT ME ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II G�20UT.rINSPECTTIIONN PHASE III/FINAL INSPECTION f n <br /> TNSPFrTTnM RV 7 ,,4�Y— ^T]ATR��'/ 7� =TNSPF:C7I�}N BY DATE b/ R <br />