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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 'OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Z; , Telephone: ,x(209) 466-678134 /. <br /> APPLICATION FOR�WELL CONSTRUCTION OR PUMP PERMIT Permit No. � ._.p., <br /> THIS PERMIT EXPIRES `1 YEAR FROM DATE ISSUED Date Issued 1 2y-7G <br /> (Complete In. Triplicate) <br /> Application <br /> 'is hereby made to the Sen Joaquin LocalHealth n is infor <br /> co pliancewith <br /> tconstruct <br /> San Joaquin <br /> and/or install the work herein described. This applicatio <br /> County Ordinance No. 1'862 and the Rules and Regulations the�� Joaquin Local Health <br /> Ale <br /> dLL// CENSUS TRACT <br /> JOB ADDRESS/LOCATION �,, 44 ��l`� <br /> _ pw/ AF9 <br /> Phone ' -1�' - . X2,2. <br /> Owner's Name , .g <br /> ^ <br /> City <br /> ' <br /> Address <br /> Contractor's Name° m <br /> License #�� Phone <br /> TYPE OF WORK (Check): NEW WELL,,; DEEPEN '/7 RECONDITION I7 DESTRUCTION <br /> PUMP INSTALLATION "/ / PUMP REPAIR/ PUMP REPLAC _•. <br /> Other <br /> DISTANCE' TO NEAREST: SEPTIC TANK �k, SEWER.EINES PIT PRIVY' <br /> fes'' SEWAGE DISP SO A/�L FIELD �.� CESSPOOL/SEEPAGE PIT� OTHER <br /> i PROPERTY LINE - P+RIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavatio c ' <br /> Industrial ., � <br /> Domestic/private Drilled Dia. of-Well Casing <br /> Domestic/public Driven ,- Gauge�of- Casing <br /> IrrigationR� Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal. Other �_ Other Information <br /> Geophysical _ - Surface Seal' Itstalleid 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. _ <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done--` <br /> �DE&TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 11 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 <br /> WELL DRILLERS REP of the well and notify them before putting the..well. in.use-... .The above <br /> information is rue to�the-best of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> `%�IOR TO G G AND ECT 0 <br /> ,IGNED TITLE <br /> (DR AW_PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE . th14-4� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHAS I GRO INSPECTI PHASE,-III FINAL INSPECTION 6 <br /> INSPECTIONBY DATE INSPECTION BY , ` DATE d <br /> V U 1AIA uet._ 1_7A <br />