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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP: OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7g—�] <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �Z8" <br /> I (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 /> L County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health. AistricX. <br /> k ; <br /> JOB ADDRESS/LOCATION + CENSUS TPACT <br /> rf-Ctl is , <br /> r Owner's Name Phone <br /> Address,-P,o 422, LoCA-egard. City . <br /> Contractor's Name License # Phone 7 -+~ p <br /> NJ <br /> TYPE OF WORK (Check) : NEW WELL/_ DEEPEN /_/ RECONDITION _ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /� . <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY •� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER zjj <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/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack. Depth of Grout Seal <br /> kCathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical w Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. " . . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP:REPAIRSState Work Done <br /> C- 6p,i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby a to comply with all laws and regulations of the San Joaquin Local Health istrict <br /> gree P Y <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 8 <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-well in use. The above <br /> information s e . to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A FINAL INSPECTION. <br /> TITLE <br /> SIGNED f <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 /> INSPECTION BY DATE INSPECTION BY DATE + T <br /> 1117 2K <br /> u U 1 L9A no.r 1_7A <br />