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SAN JOAQUIN-LOCAL, HEALTH DISTRICT ' <br /> E'OE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �v <br /> t <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 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 /> Cit i - D, 1s ► '. 74�° <br /> A) -, 0(3 -- 0(-a Zg ;. <br /> JOB ADDRESS/LOCATION' / ZQ . S 1 OF ✓MJ ISUS TRACT <br /> Owner's Name Phone <br /> x <br /> Address City <br /> Contractor's Name Lic 'n e #2 5Phone -Y'/ZZ- <br /> _ a <br /> kREPLACENEliT— <br /> TYPE OF WORK (Check}: NEW WELL / DEEPEN / / RECONDITION / / TRUCTION /7 <br /> PUMP INSTAL ATION / �/ PUMP REPAIIr�, /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER ; IN S"' PIT PRIVY ' <br /> SWAGE DTSPOSAL 'F D ESSPOOL/SEEPAGE PIT OTHER <br /> I PROPERTY LINE - P AT , DOMESTIC WELL. PUBLIC DOMESTIC WELL . <br /> INTENDED USE TYPEOF WEUd : <br /> CONSTRUCTION SPECIFICATIONS / <br /> - 'Industrial Cabl Dia:�afWe1T Excavation / <br /> Domestic/priva.te DrilDia. of_ <br /> -Well' Casing <br /> ,Domestic/public Driven i 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 Seal Installed. B . <br /> . PUMP INSTALLATION: Contractor t <br /> Type of Pump H,P. . . <br /> r � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR:. / / State Work Done : <br /> IDES-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 �completi n 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 GRO D A'FIN ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ,I \ ; <br /> APPLICATION..-ACCEPTED-BY. - — -- - `'�---DATE � = - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> rINSPECTION BY DATE INSPECTION BY DATE <br /> 'r <br /> 1177 - 2M <br /> P " 1L9A Pair- I_7G <br />