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c <br /> -�-1 JOAQUIN LOCAL HEALTH DISTRIC'.,_ <br /> L OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V Telephone: (209) 466-6781 <br /> APP CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. --', � <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued E�6 <br /> Li '/— �� (C)mplete In Triplicate) 1 <br /> _ppl cation 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 Joaquii <br /> -ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> -JOB ADDRESS/LOCATION / ���� p �� �� ( CENSUS TRACT <br /> —career's Name �l �� /tel Phone %_' <br /> Address <br /> City <br /> _ontractor's Name �` F �S License l.D6''�' Phone <br /> _YPE OF WORK (Check) : NEW WELL /3;�7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR /% PUMP REPLACEMENT /_ <br /> Other / / <br /> 77ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS�FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL t` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation a <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 K Rotary Type of 'Grout <br /> _ Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: // c <br /> UMP INSTALLATION: Contractor G 6 x— Type of Pump H.P. <br /> ;a <br /> LIMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> r� <br /> -S.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> --Q <br /> Describe Material and Procedure <br /> 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 /> ELL DRILLERS REPORT tf he well and notify them before putting the well in use. The above <br /> _reformation is t ,to the best of m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AND A SP ION./ <br /> IGNED TITLE <br /> (DRAW PI:UOT PLAN ON RE FRSE SIDE) <br /> -RASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> PPLICATION ACCEPTED BY ' } � �— DATE f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT- NSPECTION PHASE III/FINAL INSPECTIO <br /> NSPECTION BY DATE INSPECTION BY DATE J <br /> - - - �1-7L ner <br />