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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: '� 1601 E. Hazelton Ave. , 4tockton, Calif. <br /> Telephone : (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. L7' �v5� <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 worO,.herein described. This application is made- in compliance with San Joaquin! <br /> l County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION,, ,Oa I�j�,�l`-�C 'y1n:�r ` L+� _ _- E N S U S TRACT <br /> Owner's Name Phone <br /> Address City � -c - - - <br /> Contractor s Name <br /> IL'J License 4�f 6��7 PhonL <br /> II <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN. ./—/ . RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION ( PUMP REPAIR / / PUMP REPLACEMENT I I <br /> Other / / — <br /> I� <br /> DISTANCE TO NEAREST: SEPTIC TANK *,add SEWER LINES 1.2S-1 PRIVY <br /> w SEWAGE DISPOSAL FIELD 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 Dias. of Well Excavation Q <br /> Domestic/private Drilledt Dia. of Well Casing <br /> x -Domestic/public Driven Gauge,:of Casing 2� <br /> Irrigation Gravel Pack Depth,of Crput Seal r <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal ' II Other _ Other-Information <br /> Geophysical iI. [ .y Surface' Seal Installed B <br /> PUMP INSTALLATION: ;Contractor <br /> Type of Pump ! H.P. 2- <br /> f <br /> �! � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: '!/ / State Work Done <br /> II � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to com ly with all lams 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 /> F after completion of my '!Vork 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 /> l' information is .true to1111thbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> I PRIOR TO GRO N AN NAL I CT-ION. <br /> SIGNED ; TITLE <br /> IIRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> f APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS, �I <br /> PHA1140 TjGROUT INSPECTION PHAS I/FI AL INSPECTION <br /> INSPECTION BY ' ATE INSPECTION DATE <br /> ''�.- <br /> i <br /> 2M <br />