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SAN JOAQUIN LOCAL. HEALTH DISTRICT Z� <br /> FOP.pFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7-7,-,2')-9k/ ! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '3 -777 <br /> (Complete In Triplicate) <br /> Application i9 ereby 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 0,V, IZ A. + ENSUS TRACT <br /> Owner's Name �21,J a24 �.vc <br /> Phone 222 <br /> Address <br /> City <br /> r Contractor„s Name.., License Phone ' <br /> . i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/7/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP. REPAIR / / PUMP REPLACEMENT 1-7 <br /> Other <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 C\J.s <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing h <br /> Domestic/public -41,DrivenGauge of Casing <br /> Irrigation vY Graver Pack Depth of Grout Seal <br /> Y ' Cathodic ,Pro•tection ...Rotary Type of Grout �I <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By �J <br /> PiJMf' INSTALLATION: Contractor, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: : / / State Work Done ; <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate De pth <br /> � <br /> Describe Material and Procedure <br /> J 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 TO GRPUTG AND INAL INSPECTION. ! <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> 0 PARTMET USE ONLY <br /> ;� � ! <br /> APPLICATION ACGEPTE ALIRI01 ,.. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION' <br /> INSPECTION BY I DATE INSPECTION BY DATE <br />