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I� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR .GFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. (5 <br /> 0 <br /> Telephone: (.209) .466-6781 -7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THZS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t9 the San Joaquin Local Health District :for a permit to construct <br /> and/or install. the work hereinadescribed. This application is made in compliance with San Joaquin; <br /> County Ordinance No. 1862 and+ the Rules and Regulations of the an- Joaquin Local Health .District. <br /> ,JOB ADDRESS/LOCATION � (..'D f� CENSUS TRACT <br /> Owner's Name �� Phone 11V �- <br /> � ?.F <br /> Address j '!T �l F . City .. <br /> Contractor's Name �',/cJ, C� � `7 License #rW ��� Phoned' <br /> IM <br /> a <br /> ti <br /> TYPE OF WORK (Check) : NIEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION- / i <br /> PUMP INSTALLATION PUMP REPAIR / I PUMP REPLACEMENT <br /> Ot / <br /> her 1/ <br /> DISTANCE TO NEAREST: SEPTTC, TANK SEWER LINES PIT PRIVY) <br /> SEWAM D ISPOSAL FIELD CESSPOOL/SEEPAGE ..PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE. !� TYPE OF WELL CONSTRUCTION__SPECIFICATIONS ; <br /> `'""I I-d stria? w ti u I T�; Cable Tool Dia. of Well Excavation <br /> � o <br /> _.Domestic/private i -- M-Drrlled --�= - -Dia:-of-Well Casing """ <br /> k, Domestic/public Ei Driven Gauge of Casing . <br />` Irrigation } Gravel Pack Depth of Grout Seal <br /> Cathodic Protection :,I Rotary Type of Grout <br /> Disposal r:l Other Other Information <br /> Geophysical 4 Surface Seal Installed B <br />'.`PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P. a <br /> i • <br /> PUMP REPLACEMENT: /, / State Work Done ' _ <br /> . PUMP :REPAIR: State Work Done <br /> De <br /> DESTRUCTION OF WELL. Well Diameter �' Approxa_mate Depth <br /> _ <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 Mork on a new well, I will furnish the San Joaquin Local Health District <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. 1 WILL'-CAU FORA GROUT INSPECTION <br /> PRIOR TOG OUTING A �FINA', INSPECTION. /M . <br /> SIGNED . TITLE — <br /> iM t (DRAW PLOT PLAN ON REVERSE SIDE) T� <br /> ��. FOR DEPARTMENT USE ONLY <br /> PHASE T E 77 <br /> x APPLICATION ACCEPTED BY . 0 DAT <br /> ADDITIONAL COMMENTS: ! <br /> OF <br /> PHASE II GROUT ,INSPECTION PHASE le, INALr NSPECTION <br /> INSPECTION BY II`1. DATE INSPECTION BYDATE <br /> AV <br /> 2M <br /> F. P 1426 RPv_ , 1-72 -- <br />