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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> is OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone : (209) 466-6781 �- v /� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI ei'mit No. <br /> I THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued L-RL 2� <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 ,1 <br /> County Ordinance No. 1862 and q� u and e n the S n Joaquin Local Health District, 11 <br /> F!9 �u f rid � <br /> JOB ADDRESS/LOCATION CENSUS TRACT �q <br /> + � <br /> Owner's Name ] Phone <br /> Address City <br /> Contract is Name License i Phone&- <br /> Q:IA Z7 <br /> / <br /> 4. i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN _/ RECONDITION / / DESTRUCTION /_7 � <br /> s <br /> PUMP INSTAL ATION j& PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK r4 -1 SEWER LIFE PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD I—,& .,tCESSPAOL/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 /> P""'Domestic/private -Tfri-lled­ Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q p <br /> Irrigation Gravel Pack Depth of Grout Sea] <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal .. Other Other Information �1 <br /> _ Geoph ca a ea Installed B <br /> IV4411d � <br /> PUMP' INSTALhATION: Contractor <br /> Type of PUMP L1 � ? <br /> - - - t H.P. l -. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP .REPAIR: / State Worm DonOf <br /> DES. RUCTION OF WELL: 0Diame4 A ro mate ep h <br /> Describe Material nd 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 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 G OUTING AND A KJNAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /� <br /> APPLICATION ACCEPTED BY "rte DATE 9A-Z'7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE T/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - - 7r <br /> .� a c cry r O av r <br /> _ 3- � �`�-GG�D Otiri✓F� 'G✓�LG A,�i�G�v�.�- /i�F�/N/�ilG S . �- <br />-=-E H 1426 R P v_ 1-7L �i i> vo -r 14-e-(_ �,/� �/�G 4�?- .Z n/.5�'F G 7/A�n/ , �RN7 7 2M � � <br />