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R. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �' # <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7, <br /> (Complete In Triplicate) <br /> Application ii' 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. 186 ap4 the Ru es and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION yid . --- � � . �o,� CENSUS TRACT <br /> Owner's Name 13>'r-f Ce --(0 rPhone <br /> • t <br /> Address ✓��' (� ,�i r e `� C+.` City r` a . <br /> Contractor's Name /) dt A j212 b -e �� , License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ /. DEEPEN / / RECONDITION f_1 DESTRUCTION /7 E <br /> PUMP INSTALLATION REPAIR/ / PUMP REPLACEMENT /_7 <br /> 4 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY l <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 �. <br /> Industrial Cable Tool Dia, of Well Excavation � !• <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> /Public _ . _ Driven - >.� <br /> Gauge,.•of Casing- - -L . ... <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor _ Jed- S <br /> Type of Pump ,r b . „t H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP •.REPAIR: I / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 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 GRO TING AND FINAL INSPECTION. / <br /> SIGNED ` �- - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) c <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> . k <br /> APPLICATION ACCEPTED BY + DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ' PHASE, IIIIIPIIqAL INSPECTIO -'" <br /> INSPECTION BY DATE INSPECTION BY ,s,DATE <br /> '-. } �•��ri <br /> E H 1426 Y'Rpu 1-7Aw..� I Y7.7. - 2M <br />