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71 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 4JFFIC, 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 /> 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 + Q - CENSUS TRACT . <br /> r /L�aL <br /> Owner's Name `��� �J -. .� Phone <br /> Address City <br /> . � � <br /> Contractor's Dame /n( _ . � <br /> s - License # Phone; <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN-/. / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / ] PUMP REPAIR / / PUMP REPLACEMENT /_ <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 /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />€ IndustrialCable Tool Dia, of Well Excavation ` <br /> ' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /' 11-4a ZL2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection TL/ Rotary. ..n ' - Type of Grout Z130-4117n� <br /> Ih Disposal Other Other Information `6 <br /> Geophysicalo� Surface- Seal Installed B ' <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump. i _ H.P. / + <br /> Z, <br /> r G Cf-wa2. �� <br /> PUMP REPLACEMENT: f / State Work Done <br /> PUMP .REPAIR: /. / State Work Done. - <br /> DESTRUCTION OF WELWell Diameter ` Apploximate Depth <br /> Describe Material and Procedure <br /> N <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'- 6r 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 thewell 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 GP4UTING . INAL INSPECTION <br /> SIGNED ' TITLE � ,P',, <br /> (DRAW PLOT P ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> G ADDITIONAL, COMMENTS: <br /> PHASE EI GROUT INSPECTI N f PHASE /FIN INSPECTION <br /> INSPECTION BY DATE rc INSPECTION -B _ Ft�DATE _-5-2___-7 <br /> CV <br /> F H iL9A <br /> 0/77 _ 21A . <br />