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r <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh",:DFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued6-d _ 7 <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 Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION D CENSUS TRACT . <br /> Owner's Name L * Phone 913. 3 <br /> Address g2 , B D a ,4 e- lLr3 76 City YA. <br /> Contractor's Name <br /> _ .�� �4. A �©/1�5 7'. e,.P r _.,.,.., . .License # ;16Ftly Phone <br /> TYPE OF WORK (Check).,,.,, NEW WELL /? .DEEPEN '/? RECONDITION %T DESTRUCTION J_ <br /> UIHP INSTALLATION /!•f' PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST; SEPTICTANK _x SEWER LINES PIT PRIVY <br /> /DO SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> FRbPERTYLINE �- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL \" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 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 Other Other Information <br /> Geophysical Surface Seal Installed 'B ' <br /> PUMP INSTALLATION: Contractor _ _/P a 'R <br /> Type of Pump ;�1+ <br /> A.P. I <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMPREPAIR: / / State Work Done <br /> - � <br /> DESTRUCTION OF WELL: Well- Diameter Approximate Depth <br /> Describe Material and Procedure 4 <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 Health District a <br /> WELL DRILLERS REPORT of the well andnotify them before putting <br /> the..well. in.use.... The shove � <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 FINALIN PECTION. # <br /> SIGNED TITLE {. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP�P A ION ACCEPTED BY DATES <br /> ADDITIONAL COMMENTS-: <br /> PHASE 11 GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY �+ DATE INSPECTIONBY DATE `7_-= <br />