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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> T + 666781 ._._.. .._ . ' <br /> APPLICATION ION OR PUMP PERMIT Permit No. `�7- Sl )'o� <br /> FOR WELLCONSTRUCT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date—Issued <br /> (Complete In Triplicate) <br /> j Application is hereby made to the San Joaquin Local 1lealth 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 San "Joaquin .Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's NameM4_ Phone <br /> Address { City } <br /> Contractor's Name �/✓f�4c1�/N�` Sipa lun7 License-#,, - ..Phone.-��d2-ff8o3 <br /> TYPE OF WORK (Check): NEW WELL -/-T DEEPEN '/7 RECONDITION /7 DESTRUCTION f7 ' <br /> I PUMP INSTALLATION/ / PUMP -REPAIR / PUMP REPLACEMENx f7 <br /> Other 17 <br /> l 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 WELT. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. j <br /> Industrial ' —able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.,_olf Well-Casing_ <br /> Domestic/public Driven Gauge ;of Casing j . <br /> Irrigation Gravel Pack Depth 'of -Grout Seal—,- <br /> Cathodic <br /> eal,- <br /> Cathodic Protection a Rotary Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: , / / State Work Done S <br /> PUMP ,REPAIR: ye1, State Work Done ' <br /> DESTRUCTION 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 <br /> t Health Distract " <br /> land the State of California pertainingo or regulating well:"construction. Within FIFTEEN DAYS <br /> after complefion` cif' my work'ona new well, I v11l1,furnish4 the. San Joaquin.Local Health District <br /> WELL DRILLERS REPORT-•of-the•well--and notify-them-before�putting`�e':wre11 in.use`..: The above <br /> information is true io-the best -of my.-knowledge and belief. I WILL CALL FOR A ,GROUT INSPEC ION.- <br /> PRIOR TO GR U ING AND A FIN4 SPECTION. € s <br /> SIGNED A . <br /> c TITLE <br /> (IRLW PLOT PLAN ,;ON REVERSE SIDE <br /> ` FOR DEPARTMENT USE ONLY µ< <br /> PHASE ZAPPLICATION ACCEPTED BY DATE <br /> -);> <br /> ADDITIONAL COMMENTS=:" f' <br /> `PHASE,-II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY +: DATE INSPECTION BY DATE "'-"� <br />