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A& SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> FOB4OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ) ediv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin LocalyHealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with Sen Joaquin' <br /> County Ordinance No. 186.2 and the Rules and Regulations of the San Joaquin �ocaal Health D trict. ' <br /> .. ,r , c0 B • f <br /> JOB ADDRESS/LOCATION `Etr�=US TRACT <br /> Owner's Name ` ` Phone <br /> Address> City <br /> Contractor.'s Name ._ _ ; f ,...._. _ _...�_. _._.� -. ' License Alp- C <br /> / �j. . <br /> TYPE OF YORK (Check) : NEW WELL/? DEEPEN '/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT f 7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SSR LINESL �_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD k- �-CESSPOOL/SEEPAGE" PIT ,OTHER.' ] <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL-7 <br /> INTENDED USE TYPE OF WELLv3` <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation <br /> Domestic/private Drilled Dia: of Well Casing <br />_TX Domestic/public Driven Gaugeyof Casing <br /> Irrigation. Gravel Pack Depth-of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 0therd . — Other Information <br /> Geophysical _ •----Surf ace-Seal, Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 19PH.P. <br /> PUMP REPLACEMENT: . - /,// . State Work Done _ �Xl <br /> PUMP 'REPAIR: X • <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> a <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 co' etion'o y work a n well, I will furnish the San Joaquin Local Health District a <br /> WELL DR LERS. REPO R of th w n notify them before putting the..w <br /> PRIOR GRIN D Sell in.use... The above <br /> inform tion tru to e e t of. y..know and belief. I WILL L FOR A ROUT INSPECTION ` <br /> P CTION <br /> SIGNED TITL <br /> ': _- "► & #� '(DRAW PLOT PLAN ON REVERSE SI E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE T� <br /> ADDITIONAL COMMENTS. <br /> ell <br /> PHASE II GROUT INSPECTION P SE JITIIFTAAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE 74' <br /> R R 1476 D,o i_7A -. �..r .... <br />