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YTl <br /> 1 SAN JOAQU N LOCAL HEALTH DISTRICT <br /> [FEOF, OFFIGE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephi6he: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �'7 <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ! 12-12-tZ 9 CENSUS TRACT <br /> Owner's Name /� Phone <br /> Address City <br /> ���/� <br /> k <br /> Contractor's Name ©®�' f License �G� Phone , <br /> i TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ -,RECONDITION /,f, DESTRUCTION /-7 _ <br /> PUMP !INSTALLATION / PUMP REPAIR "/' /' y PUMP REPLACEMENT <br /> Vf <br /> DISTANCE'TO NEAREST: SEPTIC TANK -. SEWER LINES PIT PRIVY <br /> `�`• SEWAGE DISP S -,FIELD CESSPOOL/SEEPAGE PIT � BOTHER <br /> PROPERTY LIN ,PRIVATE DOMESTIC WEL M-f-PUBLIC DOMESTIC WELL 2� <br /> INTENDED USE ;TYPE OF WELLF r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.'of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driveni Gauge of Casing <br /> Irrigation ' Gravel,'Pack_,_, Depth of Grout Seal <br /> Cathodi-c •Protection Y` ' Rotary'l t Tyyce of Grout y� <br /> Disposal t Other Other Information <br /> Geophysical _ Sufface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I' Cj®-r-w <br /> Type[of PumpE E H.P. <br /> d <br /> PUMP REPLACEMENT:» / / State. Work Done <br /> PUMP .REPAIR: , 4x�/ / i State Work Dane <br /> DESTRUCTION OF WELL: Well` Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 GROUTING AND A FINAL INSPECTION <br /> SIGNEDr r� LE <br /> (ARA-1-PLO(ARA-1-PLOT PLJLNN REVERSE SIDE) <br /> FOR DEP TMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE �^ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GJZOUT INSPECTION 1PHASE III/FINAL INSPEC ION .i a <br /> INSPECTION BY DATE 1Z 7, 7_7 INSPECTION BY DATE <br />