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�4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;2r-- k 34_� <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 herein described. This application 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 Q <br /> j CENSUS TRACT <br /> Owner's Name , �� } Phone r <br /> Address City <br /> teT <br /> Contractor's Name11 <br /> �� 1A�r �- .i �] License # Q Phone l- S <br /> i <br /> TYPE OF WORK (Check) : NEW WELL j1 / DEEPEN `/'.% RECONDITION _ <br /> __ _/_ /—DESTRUCTION-/ 7 <br /> PUMP_ INSTALLATION /, / _PUMP; REPAIR / / PUMP REPLACEMENT /_ <br /> Other r';l lwl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation I <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 /> Disposal Other bther .Information, <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of•-Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done ; f <br /> PUMP .REPAIR: <br /> / / State Work ;Done <br /> DESTRUCTION OF WELL;'-- `Well Diameter Approximate Depth <br /> FDescribe 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 we11 ''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 /> informati is true to the best of- my .knowledge and...belief. _I._WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T0 . UTINAM-D /A aNAIJINSPECTION. <br /> SIGNED TITLE �! <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 7 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS4 RI;IFINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY ' DATE <br /> / 2 1A7 <br /> E 14 ILM V I_7A _ 1177 2M `. <br />