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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFF-ICE USE 1601 E. Hazelton Ave. , .Stockton:, Calif. <br /> Telephone: (209) 466=6781 " ) <br /> -APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-7 7_ �d <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f- ,7 <br /> ' (Complete In Triplicate) <br /> Application is -Aereby 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 /> 3 - <br /> JOB ADDRESS/LOCATION CENSUS TRACT � <br /> Owner's Name] R1,01-To C� Phone <br /> Address Q City .5�z � ��• . <br /> Contractor's Name C L a t,(�E�L �} u ( i�Uj .License # 76&0 7 Phone 7--S <br /> - i <br /> TYPE OF WORK (Check) : NEW.-WELL. _ .._ DEEPEN /�,./ RECONDITION / / DESTRUCTION. <br /> PUMP INST LATION / / PUMP REPAIR:-f / PUMP REPLACEMENT <br /> Other L/ _ <br /> DISTANCE TO NEAREST: SEPTIC TANK 56SEWER LINES r .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 Cable Tool ` Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing */2. <br /> Irrigation ; .. ravel Pack ' - Depth of,-Grout Seal _ �, Q' <br /> Cathodic Protection K ff Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor i <br /> Type, of. Pump'. H.P. <br /> PUMP REPLACEMENT: //1 Statex Work Done »- <br /> PUMP ,.REPAIR: / / State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter- 4 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 GROUTIN AND A FINA INSPECTION. <br /> SIGNED , (� f� ��..C� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I pp, <br /> APPLICATION ACCEPTED BY �Paj,�� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY �-.sir►` _ DATE.__ -l.'.a INSPECTION BY ! _ - DATE -- ,f-7 <br />