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SAN JOAQUIN LQCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � +� <br /> Telephone: ,12 ) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��O_7? <br /> (Complete In Triplicate) <br /> G 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 /> 11t <br /> JOB ADDRESS/LOCATION 31J CENSUS TRACT <br /> k Phone - <br /> K Owner's Name <br /> City <br /> 1 <br /> Address <br /> Contractor's Name CZYOSS � .L /✓riL��iY License ��p'Z Phone 711XFUe ,, <br /> TYPE OF WORK (Check) : NEW WELL jR./ DEEPEN ,/ / RECONDITION / / DESTRUCTION /7 <br /> ` PUMP INSTALLATION /)<j PUMP REPAIR / / PUMP REPLACEMENT I-7 <br /> E Other <br /> DISTANCE TO NEAREST: SEPTIC TANK && SEWER LINES PIT PRIVY <br /> vk SEWAGE DISPOSAL FIELD ;. ,CESSPOOL/SEEPAGE PIT tom' OTHER C <br /> f: PROPERTY LINE - PRIVATE DOMESTIC WELL _-PUB LIC -DOME ST-IC WELL <br /> INTENDED USE , , TYPE OF WELL CONSTRUCTION SPECIFICATIONS . Ow <br /> Industrial Cable Tool ' Dia. of Well Excavation p2 <br /> Domestic/private Drilled Dia. of Well Casing e <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other Other Information <br /> Disposal ` <br /> Geophysical Surface Seal Installed By—AM,: <br /> PUMP INSTALLATION:'. i Contractor f H.P. 721 <br /> Type of Pump Y �. <br /> PUMP REPLACEMENT: y ' / / state Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION 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 "constriiction.f Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> k WELL DRILLERS REPORT of the well and notify them before putting the well1-in use.. The above' <br /> information is true to.the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> E PRIOR TO GROUTING A YANAL . S�&CZ09_ <br /> • <br /> TITLE <br /> SIGNEDs , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> w <br /> FOR DEPAR MENT USE ONLY <br /> PHASE I DATE o0 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ' pHAS�III/FININSPECTION -PHASE II GROUT INSPECTION INSPECTION BYDATE <br /> INSPECTION BY DATE -I - <br /> F 2M <br /> V u 1A9A nom,_ 1-74 <br />