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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209). 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./2-111Ole' i <br /> } <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued�nQ--7 7 `9 <br /> (Complete In Triplicate) . <br /> Application is 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. 1862 and .the Rule and Regu ations- of the San Joaquin Local Health District. <br /> JOB ADDRESS LOC ON / [� qa a-L"�p CENSUS TRACT <br /> Owner's Name Phone <br /> Address `�C, Q City zw d- " <br /> Contractor's Na Com/' License Phone �� r <br /> k <br /> a <br /> TYPE OF WORK (Check) : NEW WELL /_/ DEEPEN -/—/ RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 41 y <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-3 _ -CON STRUCTION_SP.ECIFICATIONS..�.t.. <br /> Industrial Cable Tool R �Dia. TofWell Excavation <br /> -Dome-s- /private -` Dzi3led - —Da a of"We11 Casing <br /> Domestic/public 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 Seacl- Installed By: ___ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` ^ H.P. <br /> PUMP REPLACEMENT: / / State Work Done `J <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 'Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree comply a to with all laws and regulations of the San Joaquin Local Health District <br /> P Y <br /> and the State of California pertaining to or regulating well 'constructi,on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the Sari rtJoaquin 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 GR TING AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> n <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE �' � -7-7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE �/� INSPECTION BY DATE <br /> 677 _ 2M <br />