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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 /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP ryPERMIT Permit No. <br /> THIS PERMIT EXPIRES `l YEAR FROM DATE `ISSUED, Date Isued 3- /O <br /> (Complete In Triplicate) :- <br /> Application is hereby made to the San Joaquin Local. Health District for a pefiA 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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r< <br /> CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address <br /> city �eL <br /> Contractor's Name License 4 I Phone ' <br /> .. <br />' TYPE (Check) :OF WORK NEW WEL _ _ _ <br /> L DEEPEN / /, _,RECONDITION/ / •-DES�RUGTION /.� _ <br /> PUMP INSTALL TION / / PUMP REPAIR /—/'—PUMP REPLACEMENT,. <br /> -Ocher <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES�� TT PRIVY <br /> SEWAGE DISP�SAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY LINE - PRIVATE DOMESTI 17 <br /> C [+]EL .(�_ rU�LIC 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 /> �( Irrigation Gravel Pack-- Depth of Grout Seal <br /> Tl� Cathodic Protection n/ Rotary Type of Grout <br /> Disposal —�+ 6tler Other Information Q U <br /> GeophysicalSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor / <br /> Type of Pump H.P. <br /> 4a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> State Work Done <br /> OT <br /> DESTRUCTION OF WELL: Wel] Diameter M A`pproximate' Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin LocaltHealth District <br /> and the,State of California pertaining to or regulating well -'construction. Withih .FIFTEEN DAYS <br /> after_. co pletion` of my work on a new well, I will furnish the San Joaquin Local Hea1'Ch-District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well in use Tlie,•above <br /> information As true to the best m knowledge and belief. I WILL CALL FOR A GRO T INSPECTION <br /> PRIOR TO GROUTING A F NA SP <br /> SIGNED r .f _ <br /> TITLE <br /> L - -- ,�, - ----- (DRAW»PLOT_PLAN ..ON..REVERSE -SI-DE) <br /> -FOR DEPARTMENT USE ONLY- ' <br /> APPLICATION ACCEPTED BY <br /> l� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION _ _,PHASE,yI/FINAt IN5.PECTION <br /> INSPECTION BY DATEINSPECTION -BY DATE S- S - 7� <br /> E H 1426 2M <br />