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T 4 <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> iAFF76F-11601 E. Hazelton Ave. , .Stockton, Calif.•-,CE li5E: <br /> Telephone: (209) 466-67$1 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 2: 40 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 2Z,2 <br /> ��7R (Complete In Triplicate) <br /> 'hereb linade to the San Joaquin Local Health Distract for a permitetWi�hnSanuJoaquin <br /> Application is y <br /> and/or install the -work herein described. This application is.:made in comp anc <br /> County Ordinance No. 1862 and ,the. Rules and Regulations of the San Joaquin Local Health DistrcC. <br /> s CENSUS TRACT <br /> JOB ADDRESS/LOCATION , <br /> Phone <br /> Owner's Name <br /> City <v <br /> Address <br /> Phone F <br /> .License ��,��,�/1,�. ,* <br /> Cor tor's Name <br /> TYPE OF WORK (Check) : .NEW WELL/ / DEEFE RECONDITION_ DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I „ <br /> €. <br /> DISTANCE TO NEAREST: SEPTIC TAN.KZ�D`: - SEWER. LINE/ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD `,4 CESSPOOL/SEEPAGE PIT OTHER ....- <br /> I w 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 /> .—DQmest.ic:/_pr.ivate Drilled - _ Dia.. of Well Casing <br /> .w Domestic/public <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other .. Other. Information e tc <br /> h Disposal - <br /> Geophys, cal ; Surface`Seal Installed B : <br /> PUiT' INSTALLATION: Contractor. <br /> Type of`Pump -'' H.P. . . . . <br /> / / State Work Done t ~ <br /> PUr1Pi ];-.PLACEMENT: � <br /> pUMB REPAIR. - - "" /--/— State "Work Done <br /> Approximate Depth ' <br /> DESTRUCTION 6F WELL: Well Diameter <br /> Describe Material '-and Procedure - <br /> hereby th alregulations of the' 'San Joaquin Local Health District <br /> I agree to comply wil laws and <br /> well <br /> and the State of California pertaining to or regulating construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District E <br /> . WELL DRILLERS REPORT 6f the <br /> well and notify them befoputting <br /> tti WILL FOR A GROUTeIN$PECTION <br /> information is true to -the b t my k ledge and belief. <br /> PRIOR TO_GR94 NG DA FIN I E TITLE <br /> SIGNED <br /> W PLOT PLAN ON REVEJPSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL COMMENTS-. p II/FI INSPECTION <br /> PHASE II GROUT INSPECTION ,INSPECTION B DATE r- <br /> INSPECTION BY DATE <br /> Y- <br /> ° 2M <br />