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X SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F R OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> e <br /> THIS PERMIT EXPIRESIYEAR FROM DATE ISSUED Date Issued/o(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-FaDd--Re la. ns of the San Joaquin Local Health District. <br /> V <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT c� i <br /> Owner's Name <-C-P 57 ane X76 G t <br /> Address 7 � City <br /> i <br /> Contractor's Name ` License Phone -_ - ' <br /> TYPE .OF._WORK, (Check) : _-NEW.WELL %_/ --DEEPEN /_/ RECONDITION-/. / DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR. / / PUMP REPLACEMENT f / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ' OTHER <br /> PROPERTY LINT. -- PRIVATE DOMESTIC WELL __ PUBLIC DOMESTIC WELL <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 /> r. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <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 furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use.. The above <br /> E information is true t the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GJIOUTING jk FINAL INSPECTION. <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /3 / <br /> APPLICATION ACCEPTED BY DATE / 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE ,II GROUT INSPECTION,, PHASE ;II/FIN4L INSPECTZ N <br /> INSP DATE '' INSPECTION BY DATE <br /> 7 A I � 1lC oer 4,4X 4 q-, A v.C�� , 4a <br />