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SAN JOAQUIN LIJCKL ICEALTH DISTRICT !� <br /> FOR OFFICE USEc 1601 E. Hazelton- Ave. , Stockton, Calif. d� H � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRbCTION OR PUMP PERMIT Permit No. -S 3 <br /> ?7�6�t�-7° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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. I <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owaer's Name Phone <br /> i <br /> Address ° City :5" l� <br /> i <br /> Contractor's Name AM afz�,;S: License #2 Phone <br /> TYPE OF WORK (Check) : NEW WELL EEPEN / / � RECONDITION / / DESTRUCTION <br /> /, <br /> PUMP INSTALLATION 4�PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other'/—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK /f} * - SEWER LINES /� PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY -LINE -- PRIVATE DOMESTIC- WELL PUBLIC DOMESTIC WELL <br /> UNTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> 4Industrial it L Cable 'Tool Dia. of Well Excavation ze <br /> t, ,Domestic/private Drilled Dia. of Well Casing f <br /> :Domestic/public W Driven Gauge' of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 15,7 <br /> Cathodic Protection Rotary Type of Grout ' an 4 *%r <br /> Disposal r * Other -Other aInformation �E <br /> Geophysical j Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 11okwe2 1,2 <br /> y Type of PumpH.P. _ _ <br /> f <br /> e _ <br />'PUMP REPLACEMENT / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DES-TRUCTION 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 /> WEU 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 <br /> it <br /> i (DRAW PLOT PLAN ON REVERSE SIM)-- <br /> ONLY <br /> I ONLY <br /> PHASE I - 7 <br /> JAPPLICATION ACCEPTED BY DATE 7/ <br /> 'ADDITIONAL COMMENTS: <br /> E PHASE II GROUT INSPECTION PHASE, III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4;Cl DATE L:j - "? _ <br /> .V. 14 11191, Ra 7_7L �1177 2M <br />