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SAN JOAQUI LOC HEALTH DIST ICT <br /> FOFi16FFICE USE: 1601 E. Haz t n e. , Stockton, ralif. <br /> T a (209) 466-6781 <br /> APP T l; , STRU TION OR UMP PERMIT Permit No. z7_=/aVz, <br /> 1 Y DATE ISSUED Date Issued -/ ZZ <br /> - <br /> pl�t riplicate) <br /> Application is hereby mad Joaqu oca health District for a permit to construct <br /> and/or install the work n scribed. hie application is made in compliance with .San Joaquin <br /> County Ordinance No. 1 a he Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4/ / CENSUS TRACT <br /> Phone OQ <br /> Owner's Name <br /> Address CA_-) City . <br /> Contractor's Name License # " Phone , <br />{ TYPE OF WORK (Check): , NEW WELL /7 DEEPEN '/? RECONDITION rT DESTRUCTION /7 <br /> PUMP INSTALLATION ff PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t SEWAGE /SEEPAGEDISPOSAL FIELD CESSPOOL PIT OTHER - I <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 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 /> Geophysical -.Surface Seal Installed '8 <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H•P• , <br /> IPUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> 112ES•TRUCTION 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 Health District <br /> .and the State of California pertaining to or regulating well `-construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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'lthe-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE Lam* <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE "- <br /> (ADDITIONAL COMMENTS: <br /> i PHASE V1 GROUT INSPECTION PHASEIIII INAL INSPECTION <br /> (INSPECTION BY DATE INSPECTION BY - DATE <br /> . v . <br /> - - <br /> t F. H 11,,26 Rav_ ,7-7G - -. <br />