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o SAN JOAQUIN LOCAL HEALTH DISTRICT a-,. l 3 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, . <br /> Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -17-113,s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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 /> i <br /> JOB ADDRESS/LOCATION ,, t CENSUS TRACT <br /> 77 � <br /> Owner's Name f Phone �G��Z A 7 <br /> 74 <br /> Address 2 3 $Z3� l <br /> City ,eF/_ !,&W" . .0 0_ I <br /> Contractor's Name M License # iy�?;�_7P y-W7,9 <br /> X1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 k <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_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 <br /> Industrial W Cable Tool Dia. of Well Excavation <br /> Domestic/privateDomestic/ Drilled- Dia. of Well Casing <br /> Irrigation <br /> Driven Gauge of Casing <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 <br /> Type of Pump _ ! H.P. <br /> PUMP REPLACEMENT / / State Work Donee <br /> PUMP_IP'R_ <br /> 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 TING AND A FINAL INSP ON <br /> SIGNEDTITLE I'I <br /> (D L LAN ON VERSE SIDE) �CP� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE c�ir� 3,7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASFjI,1I/F1jiAL INSPECTIO <br /> INSPECTION BY > DATE INSPECTION BY DATEl/ <br /> %�'✓� � v����7_ � � �is�vs�dr-q/� ,7 �dvnrt d,,.GP.�-� 'ss��.�, � s <br />