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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: tx) 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 Issued6 -+ <br /> J (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 Joaquin <br /> County Ordinance No-.- 1862 and 'the Rules and Regulations of the San Joaquin Local Health District. . <br />.JOB ADDRESS/LOCATION �ArCC,4CENSUS TRACT <br /> CL Phone <br />'Owner's Name <br /> City <br />`Address C f <br /> > ' r License �� #0 Phone <br /> CsntraCtor s Name Q Q v <br /> TYPE .OF WORK (Check) : NEW WELL / DEEPEN V RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLAMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY 06 <br /> SEWAGE DISPOSAL FIELD .. CESSPOOL/SEEPAGE PIT OTHER S <br /> PROPERTY DINE - PRIVATE,DOMESTIC WELL' PUBLTC_DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> t �� <br /> ., Cable Dia. of Well Excavation <br /> Industrial Tool <br /> Domestic/private 3 Drilled .w*Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation t Gravel Pack *Dep•th of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other Information <br /> Disposal Other <br /> # Geophysical Surface Seal Installed By:--', <br /> PUMP INSTALLATION: Contractor f1 H.P. _ <br /> Type of Pump <br /> 1PUMP REPLACEMENT: / / State Work Done <br /> 1 � 3 ,3 _ e 't <br /> PUMP REPAIR: / / State Work Done <br /> f. Approximate—DEP the <br /> pESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> i' <br /> I 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 /> WELL DRILLERS REPORT of the well and notify them before putting the well- in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING ANTI A FINAI _- <br /> NSPECTION. TITLE <br /> GNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T � � / DATE <br /> APPLICATION ACCEPTED BY �" <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE ? ; z 7 7 <br /> .,INSPECTION BY :DATE w - ' <br /> 7f77 2M <br /> k <br /> rt u IL94( Row- 1-74 <br />