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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466--6781 / <br /> F <br /> J APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��-�P <br /> ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> cfOV.N. D 1,�14ES- 4J . (Complete In Triplicate) 7"I. j . 003--ren---e23 <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 n compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the S Joaquin Local Health District. <br /> JOB ADDRESS/LO ATION �LlCENSUS TRACT <br /> i <br /> Owner's Name -k Phone <br /> I <br /> Address City <br /> i <br /> � r <br /> Contractor's Name t License # of <br /> /Phone <br /> TYPE OF :WO„RK. (Check) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 1 '� <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other {v <br /> DISTANCE ':TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY Q 01 <br /> SEWAGE DISPOSI <br /> FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F PROPERTY LINE - PRIVATE DOMESTI_C__WELL_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ble. Tool Dia, of: Well Excavation .. <br /> Domestic/private Drilled Dia, of Well Casing Alf <br /> Domestic/public Driven Gauge of Casing <br />___L,,-T-rrigation Gravel Pack Depth of Grout Seal (� <br /> Cathodic Protection Rotary Type of Grout 1, <br /> Disposal Other Other Information f a <br /> Geophysical Surface_ Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ ti <br /> .-. -- - Type of Pump w H.P. ` <br /> ! � I <br /> PUMP REPLACEMENT: / / State Work Done j <br /> PUMP---.REPAIR-: -` / '-State'Work Done <br /> DES=TRUE CTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' <br /> ,s <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District= <br /> and the State of Califo.rnia. per taifting ,to�or' regulating well *construction. Within FIFTEEN DAYS <br /> after completisi�zof,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 wellin use. The above <br /> information is true to the t o my knowledge and belief. I WILL C L FOR A GROUT INSPECTI N <br /> PRIOR TO GROU NG AN A FI ECT N. <br /> SIGNED TITLE r <br /> (DRAW P OT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE s• - 7t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , /'� DATE 7-104 <br /> F. T� 7L9F, uotr 1_7/1 <br /> 1f77 . _ 2M <br />