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�a f. r a� / SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOE-OFF CE USE: V 1601 E. Hazelton Ave. , . Stockton, Calif. <br /> Telephone : (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> RMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /3/ <br /> THIS PE 2,03 - <br /> (Complete In Triplicate) <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in .compliance with San Joaquin <br /> County Ordinance No. ,18 2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB'ADDRESS/LOCATION. Y ��p ° `` �� p CENSUS TRACT . <br /> Phone <br /> Owner's Name �Q ►% l a <br /> i -- <br /> Address / _! City <br /> ' Name License # / 37k1Phone <br /> Contractors <br /> TYPE OF WORK (Check} : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP�REPLACEMENT /—T <br /> Other / I Uj <br /> j W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Dry <br /> E <br /> SEWAGE bISPOSAL FIELD n. CESSPOOL/SEEPAGE PIT OTHER (Ja <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL. <br /> INTEI3DED .USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> j Cable Tool Dia. of Well Excavation <br /> Industrial . I LYJ <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 /> Other Information <br /> Disposal Other <br /> Surface Seal"Installed <br /> By- <br /> Geophysical <br /> PUMP INSTALLATION: Contractor. H.P. 7= <br /> Type of 'Pump cc <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: IXI <br /> State Work Done <br /> ppr1oximate Depth <br /> ' DESTRUCTION OF WELL: Well Diameter <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 /> y, af--ter 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 knowled .e_and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUING AN A FINAL INSPE2(D <br /> N •c~ TTLE _ �^�.�, — <br /> SIGNED '' <br /> PLO PLAN ON R RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ' " <br /> APPLICATION ACCEPTED BY <br /> " ADDITIONAL COMMENTS: PRASE III/FINAL INSPECTION <br /> PHASE II OUTI.INSPECTION DATE6_�.�_ <br /> INSPECTION BY DATE INSPECTION BY <br /> 6 . _ 2M. <br /> F 'R 1676 Rov. • I-74 <br />