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•" r <br /> y1fM�� <br />,4�5 itsiA <br /> SAN JOAQUIN LOCAL HEALTH DISThICT <br /> FOh'OFFICE USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> --!! A°PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> "'IS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued WiRL <br /> (Complete In Triplica' -) <br /> Application is hereby made to the San ;oaquin Local Health L._ t ict for a pernit to construct <br /> and/or i•►stall the work herein described. This application is made in compliance with San Jct <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distri <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> e) <br /> Owner's Nar,e Phone _ <br /> t <br /> Address <br /> 3.S city y <br /> Contractor's Name License �zs:� Phoneplt <br /> TYPE OF kORK (Check): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION .0 PUMP REPAIR /_7PUMP REPLACEMENT /7 <br /> Other L7 <br /> DISTANCE 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_ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> < Domestic/privateDrilled Dia. of Well Casing �� _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Fack Depth of Grout Seal <br /> Cathodic Prote-ction Rotary Tvice of Grout <br /> Disposal Other OthCr Informations,/ <br /> Geophysical Surface Seal Installed By: <br /> Y <br /> PUMP INSTALLATION: Contractor AIA a z Fv e �A <br /> Type of Pump Al &2o/, H.F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Dore <br /> DESTRUCTION 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 Distri <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DN <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri, <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to t est of my knowledge and belief. I WILL CALL FOR A GROUT IFSP_"^.TIC <br /> PRIOR T9, Gf NG A D :AL I SPECI'ION. <br /> SIGNED TITLE C + <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPART NT USE ONLY <br /> PHASE I J / DATE /F 7 C7 <br /> APPLICt,7'ION ACCEPTED BY , i .-r <br /> ADDITIONAL COKL*ENTS: <br /> r11ncF TT GROUT TNSPECTTON P FINAL INSPECTIPN <br />