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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F06 'OFFICE 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 Issued <br /> I (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 Jo4qu <br /> County Ordinance No. 1862 andAhe Rules and Regulations of -the San Joaquin Local Health District <br /> { / <br /> JOB ADDRESS/LOCATION 19 -5-30 S., crc2_Cd"7tc��,P /�—, CENSUS TRACT <br /> Owner's Name j�g rrpS �� (��� Sl �h Phone - Ool <br /> S' 1 <br /> Address f! p/ City 4 y/e G etj <br /> /"� �' S � `� �' � ? � 11 <br /> Contractor's Namep — � PhoneI�cense � ' <br /> TYPE OF WORK (Check) : NEW WELL/�;K DEEPEN '/_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: ,,-SEPTIC TANK �t-SEWER LINES jg0 _7"`PIT PRIVY <br /> -}- SEWAGE DISPOSAL ELD �� CESSPOOL/SEEPAGE PIT _ OTHER l� <br /> PROPERTY LINE29 IVATE DOMESTIC WELLI(,---' PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> t/ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 1,t- Gravel Pack Depth of Grout Seal -,f5n <br /> Cathodic Protection Rotary Type of Grout mem 2 <br /> Disposal Other Other Information <br /> I Geophysical Surface Seal Installed By: <br /> c <br /> PUMP INSTALLATION: Contractor ��D(At=--914 <br /> Type of Pump H.P. <br /> M - <br /> PUMP REPLACEMENT: / / State Work Done <br /> ;PiIMPREPAIR: / / State Work Done <br /> IDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> !I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> tLand 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the.'well in use. The above <br /> linformation is true to the best of my knowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE ;I <br /> (DRAW PLOT PLAN ON REVERSE •SIDE) i <br /> FOR TMENT• USE ONLY " 7 <br /> !PHASE I ji) DATE <br /> APPLICATION ACCEPTED BY <br /> 'ADDITIONAL. COMMENTS <br /> PHAS II GMT INSPECTION P SE I/FIN INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I <br />