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C / SAN JOAQUIN LOCAL HEALTH DISTRI.Ci <br /> FOF. CFFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, Calif. / _77�& <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. A5-41,�P <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 Joaqu; <br /> 'ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION C r � r _-- =' CENSUS TRACT <br /> er's Name ,� f '�� t t �, Phone /J <br /> Address 11 6a� /L�✓/ib�J �/ City @c EYE <br /> -montractorIs Name pi g �, License # if3'iS�Phone <br /> ,..YPE OF WORK (Check). NEW WELL /7 DEEPEN /% RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR �/ PUMP REPLACEMENT 17 <br /> Other /_7 <br /> ISTANCE 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 F <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ON <br /> X 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 /> UMP INSTALLATION: Contractor C \ ZZ <br /> UMP / ' -i <br /> Type of Pump -a r ,4, H.P. u <br /> UMP REPLACEMENT: E7 State Work Done _ <br /> PUMP .REPAIR: State Work Done r o-: i� !i" �f✓ t <br /> 3STRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 19nd the State of California pertaining to or regulating well conseruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> %,oformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 TING AND A FINAL SPE!CTION. n <br /> IGNE / r -"ATITLE <br /> (DRAW PI OT PLAN ON VERSE SIDE) <br /> IASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I PECTION PHASE III/FINAL INSPECTION <br /> VSPECTION BY DATE INSPECTION BY DATE 63'?!a <br />