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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> For% OFFICE USE: Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. �. <br /> 6 <br /> Date <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Issue LLLE=2,1, <br /> (Complete In Triplicate) <br /> IImade to the San Joaquin Local Health District for a Permit <br /> ct <br /> Application is hereby $t iChnSanuJoJoaquin <br /> his applicaio <br />' and/or install the work herein described. <br /> eandRegulationsvf <br /> scribaTtntha San <br /> Health District. <br /> County Ordinance No. 1862 and t <br /> 1 SUS TRACT <br /> t JOB ADDRESS/LOCATION <br /> tPhone <br /> Owner's Nage <br /> ASIR Is". <br /> City . Al <br /> Address <br /> License $ Phone v�4�� <br /> Contractor's Name <br /> ON <br /> TYPE OF WORK (Check)-. NEW WELL I�DEEPEN 'l GOND R�/� PT3M�'ITON f-7EREPLACIEMEN�I? <br /> PUMP.`INSTALLATION /C. ;7P <br /> Other / 7 <br /> I <br /> PIT PRIVY _ <br /> .DISTANCE TO NEAREST: SEWER LINES SEPTIC TANK _ CESSPOOL/SEEPAGE PTT OTHER <br /> SEWAGk DISPOSAL FIELD_ <br /> ELL*_ IC WELL <br /> LINE - PRIVATE DMSTIC PE CATIONS O gTRUTO <br /> INTENDED USE TYPE OF WELL <br /> e able Tool' - -Dia. of Well ExcaVation <br /> Industrial <br /> t__---Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing .� -- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> i Cathodic Protection Rotary Type of Grouts 5 <br /> Other Other Information <br /> Disposal <br /> s <br /> Surface Seal Installed 'B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> F Type .of Pump <br /> i <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP +REPAIR: / /i State Work Done <br /> f r Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> f F� <br /> T 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 /> I after completion of my work on anew well, T will €urnish .the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the -wellin.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 GROUTIN AND A FINAL INSP N. <br /> TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE STDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE .2 DATE 7� <br /> APPLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS l FINAL INSPECTION ' <br /> PHASE II GROUT INSPECTION DATE <br /> ` INSPECTION BY DATE <br /> INSPECTION BY <br /> r <br />