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SAN JOAQUIN LOCAL HEALTH DISTRICT ^ <br /> FOES OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 19_-2 9 <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> /e- ' (Complete In Triplicate) 2_5'3-- 120-/2 <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 /'%eco �I,� <br /> CENSUS CT <br /> Owner's Hume Phone 1 <br /> Address <br /> 0, City <br /> Contractor's Name <br /> Licensees /��6y <br /> TYPE OF ,WORK (Check,): NEW WELLJO DEEPEN /7 RECONDITION /-7—DESTRUCTION-/77--- - <br /> - - - PUMP I ALLATION� PUMP REPAIR /-7—PUMP REPLACEMENT f T <br /> Other <br /> A <br /> DISTANCE TO NEAREST: SEPTIC TANK 1d� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL/IELD CESSPOOL/SEEPAGE PIT OTHER �. <br /> ' PROPERTY LINEN PRIAC MESTIC WELL PUBLIC DOMESTIC WELL �} <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -4- <br /> Industrial <br /> Industrial Cable Tool Dia. of Well Excavation <br /> C, Domestic/private Drilled Dia, of Well Casing 's <br /> Domestic/public Driven Gauge of Casing Q <br /> ------- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic.Protection :0:: Rotary Type of Grout <br /> Disposal. Other r� Other Information f <br /> Geophysical Surface Seal Installed 'By: ��c1 i <br /> I <br /> PUMP INSTALLATION:" Contractor et r <br /> Type .of Pump H.P. ZZ <br /> PUMP REPLACEMENT: , , / / State Work. Done <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 furnishithe 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..knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO G TING ' D AAINAL INSPECTION. <br /> SIGNED TITLE -7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE• ,, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Q,Q.�.Z DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY ATE ' <br />