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jSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F( F_ OFF-ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> %, Telephone: (209) 466-678 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER Date Issued <br /> ; (Complete In Triplicate') <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> � ibed. This .a plication is made in compliance with San Joaquin <br /> and/or install the work herein .descr p <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT ' t <br /> JOB ADDRESS/LOCATION p c 1 ? <br /> I, Phone _., <br /> Owner's Name - --� <br /> 11 City - <br /> Address L4 3 _ <br /> ,f Phone 3 O <br /> M �' License # G <br /> Contractor' s Name ' <br /> �R <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION—/--PUMA REPLACEMENT <br /> / DESTRUCTION _ <br /> PUMP ZNSV LATION / / PUMP REPAIR / / <br />` Otherd/ / <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES PIT PRIVY <br /> SEWAGEiDISPO ALFIELD CESSPOOL/SEEPAGE PIT J��_ OTHER . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � R <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation , <br /> Domestic/private 1 Drilled Dia, of Well Casing V <br /> Bome•stic/public 1 Driven Gauge of Casing Ia <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Other Other Information <br /> Disposal <br /> Geophysical r� Surface Seal Installed BY: aF <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type sof Pump <br /> PUMP REPLACEMENT: f / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: WellDiameter <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 /> fWELL 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 /> PRIOR TO G OUTING AND A FINAL-INSPECTION. TITLE <br /> SIGNED <br /> t - (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> I ADDITIONAL COMMENTS: <br /> PHASE III/FINAL INSPECTIO <br /> PHASE II GROUT INSPECTIONDATE" 3 " <br /> INSPECTION BY / DATE V=`' <br /> ST NS PELT ION'iBY''"� _e'✓Q�-... <br /> /yo 7'i/7-7 jwCz.* 5S/ ' b/7.7 ,_ 2M/�` <br />