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SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. {" <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -/,3 V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �11 <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 and. Regulations of the San Joaquin Local Health District. <br />" <br /> -JOB ADDRESSzf_ ` �- f CENSUS TRACT <br /> Owner's Name Phone ', c <br /> Address _26 City <br /> Contractorts Name ' <br /> r� LicensePhone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN :./ / RECONDITION / / DESTRUCTION /7 _ <br /> PUMP INST LATION PUMP REPAIR /-7—PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/��OSEWER LINES / _ IT PRIVY # Y <br /> SEWAGE DISPOSAL FIELD -"'­ CESSPOOL/SEEPAGE .PIT d-ETHER <br /> PROPERTY LINT 1RIVATE DOMESTIC WELL PUBLIC 'DOMESTIC WEI'L. <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 Crout Seal <br /> Cathodic Protectioh Rotary Type of Grout <br /> Disposal YP <br /> P Other Other Information. Tf <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> jr. <br /> Type of Pump '` ��� f' H.P. -�- <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP REPAIR: / / State Work Done <br /> DES4RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 kealth District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well in use. IThe above <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO .GROUTING AND A FINAL INSPECT <br /> SIGNED <br /> • • LE <br /> PLO <br /> J PLO P ON REVERSE SIDE) <br /> OR ARTMENT USE ONLY I <br /> PHASE I 4 <br /> APPLICATION, CCEPTED BY �. <br /> . DATE Q 1�2G' <br /> ADDITIONAL COMMENTS:~ a <br /> PHASE II GROUT INSPECTION PHASE ITT/F AL..I>NSPECTION, <br /> INSPECTION—BY—.. _.._ w = . DATE INSPECTION BY DATE '7--/ -? <br /> F N YAIA n __ y moi. /i7 ..,. <br />