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9,�9►Iret r <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&.OFFICE USE.: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> p Telephone: (209) 466r-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 34J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;)/-J- <br /> r <br /> 1J-- (Complete In Triplicate) <br /> Application is hereby made to;jthe 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 thele and g ations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONX� SUS TRACT <br /> .: �. Al* <br /> Owner's Name � Phone9',.39, L- - <br /> lr. <br /> Address - - 2 -9 City <br /> Contractor's Name ' ` License „�jD�/3 Phone fed-1031 <br /> i <br /> TYPE OF WORK (Check): NEW WELL - DEEPEN/? RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR / 7 PUMP REPLACEMENT.. f7 -�... <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY rte. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE FIT 0& f q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A 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 Sea foTeA <br /> Cathodic Protection Rotary Type of Grout Ap <br /> Disposal Other Other Information ' ' <br /> Geophysical Surface Seal Installed H <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP :REPAIR: /_% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter s ' 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 regulatii 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.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN M& IN PECTI N. <br /> SIGNED 4 TITLE <br /> (DRAW PLOT LAN ON SE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION' ACCEPTED BY DATE d <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION P110 I NAL INSPE TIO <br /> INSPECTION V,7Z�22�11Z. *&�DATE 6 INSPECTION BY DATE <br />