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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB:OFFICE 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) 2p -0Sp_oS <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 As 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 <br /> 5 COly4a ENSU$ TRACT <br /> Owner's Name Phone d <br /> i <br /> Address <br /> City ,-, <br /> Contractor's Name , <br /> License V Phone �v <br /> TYPE OF WORK (Check): ANEW WELL DEEPEN '/? RECONDITION /? DSTRUCTON / f <br /> PUMP >INSTALLATION "�/ PUMP REPAIR '/� FUMP REPLACEMENT 17 <br /> Other` <br /> °t� r <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 x.. „TYPE OF WELL ,.' CONSTRUCTION SPECIFICATIONS <br /> " Industrial _ Cable".Tool Dia. -of--Well Excavation <br /> Domestic/private Drilled Dia. of We1.1_. <br /> 4 ' Domestic/public Driven Gauge of Casing <br /> g <br /> Ikon�."t orJo Gravel, Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' ' <br /> Geophysical . ._ _ . _ .. "-`�` 771-Surface Se41—Installed 'B <br /> PUMP INSTALLATION: Contractor_ . , <br /> Type of Pump. H.P. i <br /> PUMP REPLACEMENT: . f `�/ State Work Done <br /> PUMP? REPAIR: '` _ <br /> / / State Work Done .,. <br /> DESTRUCTION OF-WELL: -:"-Well -Diame-ter <br /> Approximate Depth- <br /> Describe Material and Procedure: <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 -futni.shthe San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..wel2. 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 FINAL INSPECTION.' <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I` " { ° .. FOR DEPARTMENT USE ONLY s j <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL .-COMMENTS <br /> PHASE II GROUT INSPECTION PKAS <br /> �XJIIJAFINAL INSPECT N <br /> INSPECTION BY DATE 'INSPECTION BY 4DATE ZO <br /> E H 1426 uo,r_ '1_7i _ <br />