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SAN JOA UIN LOCAL HEALTH TH DISTRICT � <br /> FO&`:0 FICE USE: 16011 E. Hazelton Ave. , Stockton, Calif. <br /> If . Telephone:' p (209) 456-6781 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> 4 <br /> THIS k'ERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sorg Joaquin Local Health District for a permit to Construct <br /> and/or install the work herein described. This',npplicatiotn 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 j m '� lm L 2�(_T)1aCENSUS TRACT <br /> .r <br /> Owner's Name Phone ' <br /> Address n City , d <br /> Contractor's Name License Phone 2,--7«4i <br /> IV <br /> TYPE OF WORK (Check) :' NEW WELL /=7 DEEPEN /'7RECONDITION /j DESTRUCTION /7AL <br /> PUMP INSTLATION/7_/--PUMP REPAIR/? PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL': PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public. Driven Gauge of Casing <br /> IrrigationGravel Pack- Depth of Grout Seal, <br /> Cathodic,Protection RotaryT - Type of Grout,� K i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> ' E�__ G�'�r �--- <br /> Type .of Pump s� H.P. - <br /> PUMP <br /> .P.PUMP REPLACEMENT: / State Work .Done .Q.Lr l4 <br /> PUMP ,REPAIR: /%. State Work Done <br />'DES•TRUCTION OF WELL: -Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <br /> I hereby agree to comply withiall 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..know.., a and belief. I. WILL CALL FORA GROUT INSPECTION; <br /> PRIOR TO GROUTING AND A FINAL ECT N. <br /> SIGNED TITLE ��> . <br /> TURAW PLOT. Pi!"_ REVERSE SIDE <br /> FOR DEPARTMENT USE.ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -�b <br /> ADDITIONAL COMMENTS: j <br /> PHASE II GROUT INSPECTION PHASE III F INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE ,r <br />