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; SAN JOAQUIN LOCAL HEALTH DISTRICT _ } <br /> ZOR OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone:: (209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 1 J <br /> THIS I PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date !I-ssued Q ; <br /> (Complete In Triplicate) r <br /> Application is hereby made tofithe 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 Sari Joaquin. <br /> County Ordinance No. 1862 an ":the les a d Reg&]ptions of„ the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION aLh <br /> �NSUS TRACT <br /> Cl 44 <br /> Owner's Name <br /> G( <br /> A���n�P . Phone <br /> Addressi. City'—al QL <br /> ' i,. . .. VIN <br /> License lII Phone . <br /> Contractor s Name <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION / I DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / I <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER { <br /> PROPERTY LINA”-=- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _- <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well ExcavationTi - <br />_ Domestic/private Drilled Dia. of Well Casing / rI <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation !:j Gravel Pack Depth of Grout Seal <br /> Cathodic Protection FI Rotary Type of Grout <br /> Disposal. .1 Other Other Information II <br /> Geophysical. � _ Surface Seal Installed By: p�p � <br /> PUMP INSTALLATION: Contractor t7 <br /> _Type of Pump <br /> A <br /> PUMP REPLACEMENT: / / State Work Done <br /> • <br /> PUMP .REPAIR: / / 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 notify them before putting thewell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> k <br /> IPRIOR[ SIGNED 0. G ANDA .FINAL, INSPECTION.P TITLE _ <br /> —�-_ _- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE S� �? ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION HASE /FIN INSPECTIO <br /> INSPEC ON BY DATE n INSPECTION ATE <br /> x W 1A9A Pss . I_7A <br />