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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 456--6781 D <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. I.ssued-3 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules andRegulationsof the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION Avz CENSUS TRACT <br /> Owner's Name Phone <br /> Address - <br /> Ci tY 4&:AUn A <br /> Contractor's Name License Phone <br /> I <br /> . � a <br /> TYPE OF WORK (ChecW"W ^/ D�-E-P=EN % RECONDITION /_/ DESTRUCTION /_ _ <br /> r�k -PUMP INS AL TION P REPAIR / / .; PUMP REPLACEMENT <br /> PL <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 Wel"! Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Gr-but Seal <br /> Cathodic Protection Rotary Type of Grout j <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor � ' <br /> of rump r H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP .REPAIR: / %-__State Work Done { <br /> ,� " G a <br /> DESTRUCTION OF WELL: Well Diameter s +°.. <br /> J� %. '�y` ���"T' <br /> - ►✓ / �E Approximate Depth .6 �-�W <br /> Describe MaCerial add"'Procedure" <br /> I <br /> I hereby agree to comply,w:th all 'rlaws and regulations of. the San Joaquin Local Health District <br /> and the State of Califo' riia p'r''tai:nirig\to or-regula�ing` 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 <br /> PRIOR TO GROUT G AND A F AL INSPECTION. S <br /> SIGNED TITLE ! <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED"BY - DATE j <br /> ADDITIONAL COMMENTS: <br /> PHASE II . OUT INSPECTION PHAn III AL CTIODJ, f <br /> INSPECTION BY % %DATE` a INSPECTION BY <br /> F'. N I li7 Rc., . 1..7A <br />