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' 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O ROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, j <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ; -,7314J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> - ' � (Complete In Triplicate) <br /> Application is hereby made to 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 Jo4quin l <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION BJ CENSUS TRACT <br /> i <br /> Owner's Name � : r 4 Phone <br /> i <br /> Address City <br /> Contractor's Name `' <br /> "" �a License # &�OPhone <br /> TYPE OF WORK (Check) : NEW WELL f / DEEPEN '/—/ RECONDITION /-7 DESTRUCTION 4 <br /> PUMP INSTALLATION ,/ / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> 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 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 4 <br /> Cathodic Protection Rotary Type of Grout tom' y <br /> Disposal Other Other Information =r <br /> C!. <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: _ v <br /> State Work Done <br /> PUMP REPAIR: / / ,State Work Done <br /> !` <br /> DESTRUCTION OF WELL: Well Diae.tr / V Apra i to Depth <br /> Describe'..Maer al and Fr cedure4. <br /> D r... <br /> I hereby agree to comply with`411.,` aws and regulations of the San Joaquin Local Health District I <br /> and the State of California pertaini.ng' 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 them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION i <br /> PRIOR TO GROVfpiG 4kjV Fja6k I,46PEMON. i <br /> SIGNED TITLE <br /> s i •i� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT .USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -� <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHA <br /> ,g, ;1_TI/jtINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE /47 7 <br /> : 1177 _ 2M <br />