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- - SAN JOAQUIN ,LOCAL HEALTH DISTRICT WW C-A� <br /> F0F' OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 --7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <br /> THIS PERMIT^EXPIRES 1 YEAR FROM DATE ISSUED, Date Issued/z'�Z�/�_ <br /> (Complete In Triplicate) . . <br /> Application is herebymadeto 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. San Joaquin. Local- Health District. <br /> JOB ADDRESS/LOCATION .. CENSUS .TRACTf IF <br /> -- <br /> 5e. i <br /> Owner's Name Phone <br /> Address �- Cit Yeac A4L�V___ <br /> Contractor's Name 4License hone'� <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPE_GIFICATION <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Rt Domestic/private Drilled Dia. of Well Casing j7 r`-r <br /> Domestic/public Driven Gauge of Casing <br /> /p \ , <br /> 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 T 4-1 <br /> I Type of Pump d . H...P-. <br /> _ Eo ° <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / ./ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material` and Procedure- <br /> } <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 theft`b'efore.putting. the well in use... The above <br /> infom <br /> ration is true to the best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT I AND A FINAL TNSP CTION.. ; <br /> SIGNED r TILc <br /> (DRAW PLOT-PLAN-ON--REVERSE SID <br /> F R DEPARTMENT USE ONLY <br /> € PHASE Iat"— <br /> .. APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE I /FIN r INSPECTION <br /> h"`�pECTION BY DATE / -/ - 7 INSPECTION: BY. DATE V <br /> IN 7L96 RPv_ l—Ila <br />