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tell,S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> FOF�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7K_,5—_s-,7,r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedZ /3�7&/ <br /> (Complete In Triplicate) See A&& Pzv.-1',Vd 70/k/ <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 Joaquirii <br /> County Ordinance No. 166.2 and the Rules and Regulationshe Sa Local Health District. <br /> JOB ADDRESS/ Joaquin ATION SUS TRACT <br /> Owner's Name Phone ✓ : d <br /> Address 72- <br /> Contractor'a <br /> 2- <br /> Contractor'a Name Z—J ,��t��j �j License /4.>"37j�hQne 4L 96D-r— <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN '/? RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATI$Nf PUMP REPAIR'/_7PUMP REPLACEMENT /7 <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE r- 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal _ Other Other Information ' <br /> Geophysical rface Seal Installed By. <br /> PUMP INSTALLATION: Contractor . . . . . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR:. State Work <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 GROUTING AND A FINAL INSPECTION. / <br /> SIGNED TITLE cam, A A <br /> DRAW PLOT PLAN ON REVERSE SID —0- <br /> F'OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE ' ? 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL 114SPECTIO14 <br /> INSPECTION BY DATE INSPECTION BY DATE le, 7- <br /> 7._7/. I 1 /�.,_ 1. /+2e .0 <br />