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SAN JOAQUIN LOCAL HEALTH' DISTRICT <br /> FOR OFFICE 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 7 YEAR FROM DATE ISSUED Date Issued Z , <br /> (Complete In Triplicate) I <br /> Application is hereby made to the San Joaquin Local. Health District fora permit to construct <br /> and/or install the work hereinl. described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andE',the Rules and Regulations of the San Joaquin Local Health District.- <br /> JOB ADDRESS/LOCATION /1/ CENSUS TRACT <br /> F l <br /> Owner's Name 3Gq-� © lam <br /> c �c -�� N'�h �Z Phone <br /> t <br /> Address City <br /> r :7 License ��1Phone <br /> Contractor's Name - - <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ea ' ,SEWER LINES 1 a1 PIT PRIVY <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 <br /> Industrial Cable Tool Dia. of We11 Excavation <br /> Domestic/private Drilled Dia. of Well'-Casing <br /> Domestic/public if Driven Gauge of Casing �. <br /> Irrigation ti Gravel Pack- Depth of Grout Seal Sy a r <br /> Cathodic Protection Rotary Type of Grout {� <br /> Other Other Information <br /> Disposal i _ , <br /> Geophysical ~ Surface Seal "Installed By., <br /> t <br /> PUMP INSTALLATION: Contractor <br /> .hype` of Pump t H.P. <br /> PUMP REPLACEMENT: / / State Work Done r_ <br /> 1 <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter #Approximate Depth <br /> Describe Material and Procedure <br /> C fF <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 /> wafter 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 chem before putting_ the well in use.. The above <br /> information is true to the best o my knowledge and helef. '�I WILL-CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO T AND A AL INS ION. d� <br /> SIGNED 'TITLE <br /> 2V!::2_ ^, <br /> JA�DRAW PLOT PLAN ON REVERSE SIDE)i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / '�- -P <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ' INSPECTION BY - DATE -J- <br /> r: <br /> _. nEl7 2M. <br />