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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF .OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466--6781. <br /> APPLICAl!TION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,-2r-.0J2�- $ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' ]the <br /> (Complete In Triplicate) <br /> Application is hereby made to` 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 Joaquinf <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health Dist4ct. <br /> JOB ADDRESS/LOCATION { Al A�l CENSUS TRACT <br /> Owner's Name 1 Phone ' <br /> Address City <br /> Contractor's Name License Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL C DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION R PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY S <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 ' 1 Cable Tool Dia, of Well Excavation /Q � <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/publics Driven Gauge of Casing <br /> Irrigation 4. '1: Giavel- Pack Depth of Grout Seal .� <br /> Cathodic Protection ;, e Rotary "' --_.. Type of Grout _ } <br /> Disposal . , Other -Other Information <br /> Geophysical v , Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor`,Type of Pump,- - H.P. <br /> PUMP REPLACEMENT: / / - State Wo k' DoneM1 <br /> 7 s <br /> PUMP :REPAIR: <br /> S to-te�Work_Done_ <br /> DESTRUCTION OF WELL: Well Diametei � ��y Approximate Depth - j� . <br /> ' 'O-� GDescribe.Mae -1 andPcedure Sp' & <br /> 4 <br /> I hereby agree to comply withiall 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 onla new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of well and notify them before putting the well in use. The above i <br /> information is. tr e ' theme best of MV knowledge and belief. I WILL CALL FOR ,.A GROUT INSPECTION <br /> PRIOR TO G J) A 4-N°Al7-I P ION ' <br /> iSIGNED TITLE <br /> (DRAW .PLOT PLAN ON REVERSE SIDE) <br /> FOR-DEPARTMENT-USE-ONLY <br />` PRASE I <br /> ' -� <br /> APPLICATION ACCEPTED BY \.�� • �1«.c F °� �*,__ -__ _ DATE f-// Z <br /> ADDITIONAL COMMENTS: ., <br /> PHASEhjI GROUT INSPECTION PHA I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --trj � l <br /> V u IL9A Pa.. 1_7A _ 1xN : , ' 2M <br />