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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSFICE U5E: 1601 E. Hazelton Ave. , Stockton, Calif. [[[ <br /> Telephone:_ (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �,� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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/LOCATIONd2 . 0 , . . Al S e CENSUS TRACT <br /> Owner's Name vl': S Phone <br /> Address /� /' l O . -City _6V4,04 <br /> Contractor's Na -7474 <br /> License � 1A hone �z <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/-7. RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /^] PUMP REPAIR 1_7 PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 'PROPERTY LINE -- PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELLI <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 /> Irrigation ' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout .�. <br /> Disposal. 1 Other Other Information � <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump r H.P. <br /> 1 L <br /> PUMP REPLACEMENT: State Work Done �" 4 <br /> PUMP '.REPAIR: /7 State Work Done <br /> ,ES;TRUCTION OF WELL: W611 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complywith 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 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 e a d belief. I WILL CALL FOR,A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECT 0 <br /> SIGNED ITLEr <br /> JPWT PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ' PHASE II FINAL INSPECTION ' <br /> INSPECTION BY DATE ' INSPECTION BY DATE 4 J` <br /> 1 ;.-E. g. 1� 6 _. - <br /> .Rev174 � <br /> ,�. 1-74 2M <br />