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SANJOAQUIN LOCAL HEALTH DISTRICT <br /> FOh'10FFZCE-USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT.-EXPIRES 1.YEAR FROM DATE ISSUED <br /> Date Issued2_4 <br /> (Complete <br /> (Complete In. Triplicate) <br /> r Application°is hereby.mado to the San Joaquin Local llealth 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"' � � H�'�A) S721F6 <br /> ,-° 7— , + CENSUS TRACT <br /> Owner's'Namet' Q <br /> Phone <br /> Address j '� <br /> City �'+ac�.lt' "Q l� <br /> Contractor's Name e 1.np I P)4AJT 64 License # 746 Q Phone <br /> TYPE'OF WORK (Check): `NEW WELL :DEEPEN /? RECONDITION /=T DESTRUCTION /_7 _ <br /> j <br /> PUMP .INSTELATION /-- PUNP,:REPAIR /_7—PUMP REPLACEMENTther— <br /> DISTANCE TO NEAREST: SEPTIC,- TANKEWER,LINES <br /> ' t PIT P' IVY <br /> SEWAGEDISPOSAL 'IRPI;D y , ' _ CESSPOOL,/SEEPAGE--PIT- -{ - w OTHER 3 <br /> PROPERTY LINE ..DOMESTIC WELL;_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF–,,WELLIM rCQNSTRUCTION SPECIFICATIONS <br /> Industrial :Cable-,T661Dia.-of Well Excavation- <br /> Domestic/private <br /> Domestic/public <br /> "iia. .of Well Casing <br /> /Public -,Drirren .�. ;. , Gauge of Casing z . <br /> Irrigation Gravel' Pack �� 'Depth of Grout Seal <br /> Cathodic Protection Rotary to Type. of Grout: _ QE Y lel;{ <br /> Disposal Other` r •Other.Information' <br /> Geophysical.. .. { <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of iPump , : <br /> PUMP REPLACEMENT: :,, / / State Work Done <br /> PUMP '.REPAIR: 5tate4arkDnne;;, <br /> DESTRUCTION OF WELL: Well, Diameter <br /> 4 Approximate Depth <br /> Describe Material and Procedure f' :•, �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 '•cnnstruction. Within' FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the :Baia Joagddfn Local Health District* a <br /> WELL DRILLERS.. of the well and notify them before.puttih&1 thee:weAl, iri:use.:. The above <br /> information is tr. a to the•best of-my knowledge and belief. I WILL CALL .FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D A R IN ECTION. <br /> SIGNED i <br /> TITLE , t <br /> �(DRAWPLOT PLAN ON REVERSE SIDE - <br /> j�. <br /> 9 5 FOR DEPARTMENT,;USE ONLY <br /> PHASE I I ;� <br /> •. ., • - r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTIOV PHASE III FINAL INSPECTION ° <br /> INSPECTION BY DATE INSPECTION 21 ..,_DATE.: <br /> 'eI426 Rev. i Y <br /> —74 <br />