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1 i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> EOF,-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 �[ / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,711-1 T& <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ��'� (Complete In Triplicate) <br /> Application is he by 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 th San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / ` CENSUS TRACT <br /> Owner's Name Phone36 ^ .2 - <br /> Address <br /> City i <br /> Contractor's Name License # Phone�_3e7,PF[ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION /� 4 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,r SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial z---Cable Tool Dia. of Well Excavation <br /> "'Domestic/private Drilled Diae- of-Well:--Casing <br /> Domestic/public Driven Gauge of Casing r <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 By: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: y <br /> State. Wnrk Done. <br /> DESTRUCTION OF WELL: Well Diameter _-WApproximate Depth I <br /> -__ _Describe-Material and Proce&ure_,0 e <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 ofamy_ work on a new well, .I-,will furnish the San Joaquin Local Health District a j <br /> WELL DRILLERS REPORT-of the well and notify. them` before putting the-:well in use::, The above j <br /> information is true--to the best of my knowledge and belief. I WILL- CALL- FOR A GROUT INSPECTION <br />?RIOR TO GROUTING FINAL INSPECTION. <br /> SIGNED TITLE it <br /> (DRAW PLOT PLAN.-ON ,REVERSE SIDE) _ <br /> FOR DEPARTMENT- USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ;WIFINAI. INSPECTION <br /> INSPECTION BY DATE �j� — INSPECTION BY DATE 2- <br /> AM <br /> E H 1426 hPv_ 1-7[. _" -7CI 'C. &4_ , - -Vela <br />