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i <br /> 1 <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.;OFFICE USE: , 1601 E. Hazelton Ave. , Stockton, Calif. <br />' <br /> Telephone:p (209) 466-67$1 77-1-3 A`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 heroin described. This application is trade 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 CENSUS TRACT <br /> Owner's Name Phone <br /> Address v City <br /> - i <br /> Contractor's Nates _j , License #I7,V416 Phone '(4 Z 0 3 F <br /> i <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR /7 PUMP °REPLACEMENT % f <br /> Other /% t` . <br /> t <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES}' PIT PRIVY i <br /> --.SEWAGE DISPOSAL FIELD, CESSPOOL/SEEPAGEPIT OTHER <br /> PROPERTY-LIN - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - � <br /> INTENDED USE T TYPE,0F WELL t CONSTRUCTION; SPECIFICATIONS � <br /> Industrial: Cable Tool Dia. of Well 'Excavation � <br /> Domestic/pr:ivlate 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 - Other Other Informations <br /> Geophysical <br /> Surface Seal Installed 'B <br /> } <br /> PUMP INSTALLATION: Contractor -F <br /> Type .of Pump <br /> PUMP REPLACEMENT: <br /> } <br /> / / State Work Dune <br /> PUMP :REPAIR: /-7 .State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 a <br /> WELL DRILLERS REPORT of the well and,n`otify them, befgre.,putting-the.-well. in.use.. . .The above <br /> information is true to the•hest of Amy t ow_Ie_dge_andwbelief-..�.Iv,WILL-_CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING INSPECTION. <br /> SIGNED TITLE I <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> A <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE . •��= 7 <br /> PHASE IIA g§PgOION PHASE II FINAL INSPECTION <br /> INSPECTION BY TE V INSPECTION BYDATE -6-7% <br />