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.� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi;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 1 YEAR FROM DATE ISSUED Date Issued 7Z- <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. <br /> San is e3oaquinin pLvcaleHealthwith SDistrict. <br /> County Ordinance No. 1862 and the g <br /> JOB ADDRESS/LOCATION 71 . tS o�v CENSUS TRACT <br /> i Phone <br /> Owner's Name <br /> Address .� Vi-r City <br /> Contractor's Name <br /> License # t� Phone " off <br /> TYPE OF WORK (Check)-. NEW WELL--L DEEPEN:'/?" RECONDITION (�T DESTRUCTION I_T ` <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT <br /> other,,./ / . .. <br /> DISTANCE TO NEAREST: SEPTIC `TANK SEWER LINES 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 Well Excavation \ <br /> Domestic/private Drilled _, Y Dia. of Well Casing <br /> Domestic/public _ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary' - Type of Grout <br /> Disposal. Y Other Other Information <br /> Gce Seal Installed B <br /> eophysical Surf a <br /> PUMP`INSTALLATIONS Contractor <br /> a � Type.,of Pump H.P. <br /> . I <br /> PUMP REPLACEMENT: . ;State Work Done <br /> PUMP^REPAIR• / h State Work Done � Y''�out 7avL LC . <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I I hereby agree to comply with all laws and regujations 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 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 ROUTI D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> 'DgAW,PLOT PLAN ON REVERSE SID4 <br /> ;FOR DEPARTMENT USE ONLY <br /> PHASE I :- t.sy. <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ..! .. PHASE III/FINAL INSPECTION <br /> O <br /> PHASE II UT INSPECT7CON t INSPECTION BY DATE . <br /> INSPECTION BY DATE <br /> 2M <br /> to u YJ.9Gn.,.. 7-7G <br />