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SAN JOAQUICL;OCAA, HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,d-g 1?4111 <br /> - ,THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> '' ' (Complete In Triplicate) 2-2 <br /> App- ication' 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 d the Rules and Regulations of the San 'Joaquin�jo�Health District. � <br /> Wx <br /> JOB ADDRESS/LOCATION ' ' rrff <br /> (�J ENSU3 TRAGI <br /> Owner's Named Phone <br />'Address City . <br /> Contractor's Name ��- License # Phone �r?/11� <br /> TYPE OF WORK (Check) : NEW WELL � N/DEEPEN . RECONDITION /7 DESTRUCTION /7 <br /> PUMP INST TION / / PUMP REPAIR 1-7—PUMP REPLACEMENT /7 <br /> Other Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY x <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 i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> __jCDomestic/private 1—H'rilled Dia. of Well CasingS^ '.� , <br /> Domestic/public Driven Gauge of Casing ...,,_ <br /> Irrigation Gravel Pack Depth of Grout Seal � ) <br /> Cathodic FratecionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT L/ State Work Done h� <br /> PUMP .REPAIR: . . . . a .,34 <br /> '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 Districts <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.-knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> LSIGNED <br /> TO G UTING AND AL INSPE ION: <br /> TITLE L' L7 <br /> {DRAW FLO LAN N REVERSE SZD <br /> EM f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I to <br /> APPLICATION ACCEPTED BY DATE L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II1 FINAL INSPECTION <br /> INSPECTION BY DAT INSPECTION BY DATE <br /> /ne n.. <br />