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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466--6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71,P V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . <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 Rules and Regulatibns .of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o VAI CENSUS TRACT <br /> Owner's Name - t,P �� Phone <br /> Address22 City <br /> San Joaquin rump Co. <br /> Contractor's Name. (Division of San Joaquin Suip;iur Co.) License X14SjMPhone _f/q_jq <br /> 711 N. Socramelsta , <br /> j <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ % RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /4�: T_ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / - V — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER' LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD d 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/privateDrilled }} Dia. of Well Casing% %k NN <br /> Domestic/public— _ - 4--- •� Gauge- of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal s <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informations <br /> Geophysical 4 <br /> • ! Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type. of PumpYYLF � Ct'/llE - H.P. Z_ <br /> PUMP REPLACEMENT: <br /> /_� State Work Done 117-,W& <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 /> WELL DRILLERS REPORT of the well and notify them before putting- thewell in use.. The above <br /> information is true to the best of my knowledge and belief. T WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT;NG AND A FINAL INSPECTION. <br /> SIGNED r TITLE _ <br /> (MW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: —ra I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br />