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r <br /> SeLN JOAQUIN LOCAL HEALTH DISTPICT <br /> FOF OFFIfE 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 /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> ad/or instill the work herein described. This application is made in compliance with San Joaquin <br /> o.jnty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> 't ADDRESS/LOCATION /J/f // CENSUS TRACT <br /> ��`��� � /L' �4�/. pct•� �l��l) � .:Car_ t—a'� <br /> net's Name( �F J F7L c ✓� Phone a'.�' 7�' ' �•2 <br /> Addiess [� .cCity <br /> �/3 c-`` ;;{ r!� /.mac �.o� �>'�' <br /> Contractor's Name 1 / •-7'� ' <br /> License # Phene <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_ j RECON')ITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / % PUTT REPAIR / ! PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEFTIC TiNKSEWiER LINES PIT PRIVY <br /> SEWAGE DISPOSAI. FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE - PRIVATE IX)YI STIC 'tJEIL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS D <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> Domestic/private Drilled Dia. of Well Casing l,2 <br /> Domestic/public Driven Gauge of Casing � <br /> Irrigation -;;;;7 Gravel Pack Depth of Grout Seal 44 <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical Surface Sea: Installed By: <br /> _(� -- <br /> PUMP INSTALLATION: Contractor _� 0W re J <br /> Type of Puma � �•�—�T H.P. <br /> PUMP 'REPLACEMENT: / / State Work Donc <br /> — I <br /> i <br /> PUMP REPAIR: / / State Work Done Q I <br /> DESTRUCTION OF WELL: Well Diameter _ — Approximate Depth -i <br /> Describe Materi?1 and Procedure <br /> J _ _ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health 7:strict <br /> and the State of California pertaining to or regulating well construction. Within FIF'SEEN 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 TO GROUTING AND;A)FINAI. INSPECTION. �� I <br /> SIGNELY . z�_-L r.,- ir. TITLE <br /> (DRAB,! PLOT PLAN (IN REVERSE SIDE) <br /> -- FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _�p _ _ DATE '9 <br /> ,t-DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION --- PIL. ` • T I/ INA INSPECTWN <br /> INSPECTION BY DATE I::SPL:C'i'iO:d BY G DATE <br /> f: <br /> 11 1426 Rev. 1 <br />