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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,O <br /> FOF� FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,? p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) . 2_21- 04'0_// <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 thq Rules and Regulations the San Joaquin L cal Health District. <br /> Tx ' Q.- <br /> JOB ADDRESSAOCATIONL�iF CENSUS TRACT <br /> Owner's Name SJZ Phone -/ - 0 <br /> Address <br /> City " <br /> Contractor's Name „J License k7�i�1�} Phone SUE s22d <br /> TYPE OF WORK (Check): NEW WELL /=f DEEPEN /7 RECONDITION /? DESTRUCTIONf-7 <br /> R/ REPLACEMENT- <br /> Other <br /> - - � <br /> PUMP INSTALLATION / j PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j <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 <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 Other Information <br /> Geophysical Surface Seal Installed B f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . .�' State Work Done <br /> PUMP .REPAIR: / / State Work Done w <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth t <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 r <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well. in.use-... .The above F <br /> information is true to- the-best -ofmy-knowledge and belief. I WILL CALL FORA GROUT INSPECTION i <br /> PRIOR TD GROUT NG AND FIN INSPECTION. C <br /> SIGNED TITLE OA <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I' <br /> APPLICATION ACCEPTED BY1 <br /> 7i 3 Q 7 <br /> ADDITY4NAL COMMENDATE ; <br /> TS.: — <br /> .PHASE II GROUT INSPECTION PH09,11MINAL INSPECTION <br /> INSPECTION.BY DATE - INSPECTION BYIZZZL-, DATE ' <br /> E H U76 <br />