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_ ` SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOROFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2 //- <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �!7 <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 /> t <br /> JOB ADDRESS/LOCATION 44� gig 6414 hgppolc CENSUS TRACT <br /> Owner's Name Phone <br /> fr <br /> Addrcityess g � �7! <br /> Contractor's Name 4 License # 193 ' Z one — �e'ta <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /� �L <br /> Other LS <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTI,, LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL IN <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 By_: __ <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P. �0-d <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done 041 � cd C ! AW f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> j <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. the. well in use.. The above <br /> information is ' true to the best of my know?I and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OU ING AND 4 FINAL 011 1. <br /> SIGNED . TITLE _ j*y2,c <br /> (D PLOV PLAN ON VERSE SIDE) <br /> V \1_0001 FOR DEPARTMENT USE ONLY . <br /> PHASE I ATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PiTA I F NAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br />