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T / U SAN JOA UIN LOCAL HEALTH DISTRICT <br /> q <br /> FOE;OFFI. 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 1 YEAR FROM DATE ,ISSUED Date Issued <br /> � - (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 and Regulations of the Sas: Joaquin Local Health District.. ' <br /> JOB ADDRESS/LOCATION ! Of d/0, ►-, -n C <br /> •� � � CENSUS TRACT 2,01-0S0--02 <br /> V V <br /> 3 <br /> Owner's Name . .'D 0 Phone i <br /> Address _ 7" S m a J�r,� �- -- City ' 71V C,xrt 4-6-7- <br /> i <br /> Contractor's Name i a r�.1 /_/ E�yu,.,�-C] License ` 3 7a Phone 7� <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN -/7T RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR /;W PUMP REPLACEMENT /7 F <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY b 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ y,_ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: . Contractor >- -0 s,� <br /> Type of Pump u ,r - `H.P. , <br /> PUMP REPLACEMENT: . / / State Work Done <br /> ie <br /> PUMP '.REPAIR: / , State Work Done <br /> DES4RUCTION 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 then before putting.the..well. in.use... .The above <br /> information is true to the'best-of'my..knowledge and belief. I WILL CALL FORA °GROUT INSPEC ION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTl-P <br /> SIGNED TITLE _ • ��b-l' <br /> ( 'PIAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r�, �' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ,� ii ,:.a 1./7 c 9M <br />