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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F-0%;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X86 <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 />' aid/or install the work herein described. This app!ication 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 tv. ` SUS TRACT <br /> Owner's Name Phone_I(p M <br /> //�� �. <br /> Address —:2 (V. (P city ., <br /> Contractor's Name -- .. License ]_VI Phone <br /> TYPE OF WORK (Check): NEW WELL -/? DEEPEN '/7 RECONDITION /-7 DESTRUCTION /_7 <br /> / / PUMP REPAIRPUMP REPLACEMENT /_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPA�E.PIT OTHER fug <br /> -- PROPERTY LI —% ,PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE aFNELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well E cavation-,"`J <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casin �. <br /> Irrigation `,', lGriavel Pack Depth of Grout Seal <br /> Cathodic Protection , �1 RotaryTie of Grout <br /> Disposal. exT�r Other Informat on <br /> Geophysical `Surface Seal I stalled .S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu' ' H.P. 1 <br /> PUMP REPLACEMENT: State fork Done -� <br /> PUMP '.REPAIR: . _ <br /> /7 .State ork'Done <br /> DESTRUCTION OF WELL Well Diame r Approximate Depth <br /> Describe Ma�6rial and Procedure <br /> I hereby agree to comply with all _aws and regulations of the San Joaquin Local Health District <br /> and the State of California' pertai0ing to or regulating well ''cons ruction. 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 atd notify them before putting.t ..well in-use.... The above <br /> information is y4ue, to the•b st•of my- owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU7W AND A WOL INSPI_4CTT,0N. <br /> SIGNED TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY DATE , 1—Z.510; <br /> ADDITIONAL COMMENTS: - <br /> PHASE IT WUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BYDATE INSPECTION BY DATE <br />