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FSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: i 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6.781 �n7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPES 1 YEAR FROM DATE ISSUED Date Issued 3• /O <br /> (Co Tete In Triplicate) <br /> itlicition is hereby made to the San Joaquin Local Health District for a permit to construct <br /> /or install the work herein described. This application is made in compliance with San Joaquii <br /> ounty Ordinance. No. 1861 and the Rules and Regulations <br /> q of the San Joaquin Local Health District.) <br /> tADDRESS/LOCATION /O O i4 7»G/�c�n B� �nL.h c k- CENSUS TRACT <br /> er's Name /' L � - ��� Phone <br /> 'Cdress /f1_ b �fiJ City <br /> ttracctor's Name f License 11/A�-3Phone3j� & <br /> 4. <br /> �E OF WORK 'Check) : NEW WELL / / DEEPEN/ / RECONDITION /7 DESTRUCTION /7 p <br /> PlbMF INSTALLATION / / PUMP REPAIR .0 PUMP REPLACEMENT /7 <br /> other / 7 <br /> TANCE TO NEAREST: SElPTIC TANK SEWER LINES PIT PRIVY <br /> SE'4AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PRbPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL — <br /> INTENDED USE ITYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial CYe��ia. of Well Excavation <br /> Domestic/private lia. of Well Casing <br /> Domestic/publice�j Gauge of Casing <br /> — Irrigation / - Wn 4;&tDr. <br /> �r Pack Depth of Grout Seal A f <br /> Cathodic P o /i�fn ary Type of Grout �� <br /> Disposal / Other Other Information n <br /> Geophysical Surface Seal Installed By: _ <br /> JW INSTALLATION: Contractor. .� � <br /> Type of Pump T��_ _ _ H.P. <br /> L - <br /> REPLACEMENT: /;I / State Work Done <br /> REPAIR: r State Work Done <br /> TRUCTION OF WELL: Well Diameter Approximate Depth <br /> --D'bscribe"Material and Procedure ' <br /> Iereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> ter 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 not ify them before putting. the well in use. The above <br /> ormation i true 'to the best of my nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> OR TO GRO G D A INSPEC ON. c,� <br /> IGNED TITLE i j �. <br /> 1W PLOT PLAN ON REVERSE SIDE <br /> F9R DEPARTMENT USE ONLY <br /> HASE I <br /> LIGATION ACCEPTEDB i. DATE 3 <br /> ITIONAL COMMENTS:S - :y�/ ,� <br /> PHASE II GROUT INSPECTION PHASE IIA/FINAL INSPECTION <br /> SPECTION BY 114 1 DATE INSPECTION BY DATE <br />