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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.OFFICE USE: 601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -117 9re) <br /> 765-,s^�S� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7�..20 <br /> (Complete in Triplicate) <br /> APPlication is hereby made k•o 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 /> JOB ADDRESS/LOCATION __EE� CENSUS TRACT <br /> Owner's Name Phone '- 7C. <br /> 9,1411, <br /> Address ZSZC� Al, <br /> � > In <br /> "' City <br /> Contractor's Name r � <br /> icense'•#a-f Phone; -1 �:Z,4F, <br /> TYPE OF WORK (Check): NEW WELL /� f EPEN ./? RECONDITION / DESTRUCTION /_ <br /> PUMP INSTALLATION j / PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHER' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL f <br /> - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r�, I <br /> Industrial able Tool Dia. of Well Excavation 1 ° o <br /> Domestic/private Drilled Dia. of Well Casing <br /> D mestic/public _ <br /> �-.�- --�-Driven M-� �` - ��- --- <br /> � l <br /> Gau e'of''"Casi'� - <br /> Irri ation g, g v <br /> 8w Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. Rotary Type of Grout \� <br /> Disposal - Other Other:-Infa oration ~, �s <br /> Geophysical, <br /> SurfacE' Seal Installed By ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H. . <br /> PUMP REPLACEMENT: , /—/ State Work Done ' <br /> PUMP .REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: We11. Diameter <br /> 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 notifythem before <br /> putting..the..we11. in.use... .The -above <br /> information is true to the-best .of-my_knowledge and belief. I WILL CALL 'FOR A GROUT I <br /> NSPECTION i <br /> PRIOR TO GROUTING D FINAL°' SP <br /> SIGNED I <br /> TITLE ���-� � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIONACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY = DATE <br /> E H 1426' Rev. 1 74r !./7c 7M <br />