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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOK'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - <br /> THIS <br /> o. -THIS PERMIT• EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> F (Complete In Triplicate) <br /> Application As hereby made tolthe San Joaquin Local health District for a permit to constnJo � <br /> and/or ,install the'work herein described. This application is made in compliance with San oaquin <br /> County Ordinance No. ,1.862 and tha Rules and Regulations of the San Joaquin Local. Health District. <br /> Of v - i CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's -Name' . (2ze,2 011 Phone <br /> Cit .: . . 4 <br /> Address - • y <br /> r: y. License <br /> Phone ,?- <br /> Contractor's Name -t <br /> TYPE OF WORK (Check) : NEW LL.-Y DEEPEN '/_7 RECONDITION. /? DESTRUCTION f7 <br /> PUMP INSTALLATION f_1 PUMP REPAIR/_7PUMP REPLACEMENT /=T i <br /> Othe� <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 i Cable Tool Dia. of Well Excavation & �} <br /> Domestic/private i Drilled Dia. .of Well Casing - p <br /> ' Domestic/public r Driven Gauge—of Casing <br /> Irrigation �: Gravel Pack Depth of Grout Seal <br /> p <br /> Cathodic Protection i _ Rotary Type. of Grouter <br /> Disposal 1 Other Other Information ' <br /> Geophysical A Surface Seal Installed B <br /> PUMP INSTALLATION: ; Contractor <br /> Type, ,cif Pump H.P. . <br /> el <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_7 State Work Done -'° ` `'� ✓ ' <br /> 4DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> .Y - <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land the State 'q' f 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 /> I, WELL DRILLERS REPORT of the viell and notify them before putting- the-well in.use.... .The above <br /> inform tion is true to the.best of my-knowledge and belief. I WILL CALL 'FOR A GROUT INSPECTION <br /> PRIOR G TING A FINAL INSPECTION. <br /> 'SIGNS TITLE <br /> `f (DRAW PLOT PLAN ON REVERSE SIDE — <br /> FOR EPARTMENT USE ONLY , <br /> P SEI � -- - ~ <br /> CATION ACCEPTED BY DATE Z2 L/ G <br /> ,ADDITIONAL COMMENTS: t <br /> P I UT iNSPECT19 PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> OA <br /> s <br /> R H 1426 Rpv. 1-74T F. r f <br />