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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR OFFICE USE: D` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELT: CONSTRUCTION OR PUMP PERMIT Permit Noy? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Iss ed <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 Jo4quin ! <br /> County Ordinance No. 1862 and 'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSyIT,BGAr9AF f Z CENSUS TRACT <br /> Owner's Name Phone <br /> Address City f <br /> ow <br /> Contractor's Name Moo 0 License Afyhone <br /> z <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 `. <br /> PUMP INSTALLATION `�' PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ..SEWER LINESf®Q- -PIT PRIVY <br /> SEWAGE DISPOS FIELD .- CZ&S nnLISEEPAGE PIT -OTHER �— <br /> PROPERTY LIN <br /> 'PI <br /> DOMESTIC WELL &" - PUBLIC DOMESTIC WELL ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial,,,.,, �. . --4- --Cable <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public , Driven Gaugelof Casing <br /> Irrigation ! Gravel Pack' Depth bf' Grout Seal <br /> Cathodic Protection = Rotary Type of Grout � r.�.1 . <br /> Disposal _ _ Other Other-Information <br /> Geophysical Surface Seal Installed By: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump /Z_7 4W _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> � I <br /> PUMP .REPAIR: / / State Work Done <br /> jDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure— _� n <br />'' I hereby agree to comply with all laws and-regulations of the San Joaquin Local Health District <br /> pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> rand the Stare of Californiap t g g g <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 myknowledge a d belief. I 'WILL CALL FOR A GROUT INSPECTION <br /> 1PRIOR TO GROUTING AND A FINAL INSPECTI <br /> SIGNED E ''' <br /> DRAW PLOT YLAN ON REVERSE SIDE i <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br />,APPLICATION ACCEPTED BY � DATE <br /> 4 434z— <br />�ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY DATE <br /> 177 _ 2M <br /> r v IATA Dry.. 1_7/. <br />