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Co /06)-a&44� �� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO& OFF CE USE: .1601 E. Hazelton Ave. , Stockton, Calif. z. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�p <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 work herein described. This application is made in compliance with Sen Joaquin <br /> County Ordinance No. 1862 and the Rules -and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3., -S del— 7- ,0-6 CENSUS TRACT <br /> Owner's Name G o �� Phone <br /> Address 9 + / City <br /> Contractor's Name License �� Phone y — 6 <br /> TYPE OF WORK (Check): NEW WELL /� DEEP -7 RECONDITION DESTRUCTION <br /> PUMP INSx LATION l—1 PUMP REPAIR'�. PUMP REPLACEMENT .I`1` <br /> Other •I 1 <br /> C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Pn <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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal - Other Other Information ' ' <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor ' s ° <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT:' . / / State Work Done :.• f <br /> k PUMP '.REPAIR: State Work Done <br /> 1 _y i�3lfc. rT <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 construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the -San Joaquin Local Health District a <br /> ; WELL DRILLERS REPORT of the well and notify them before putting the. ell use.... .The above <br /> F information is tr a to the-best-of my knowledge a L L FO INS„ CTION <br /> PRIOR TO G AN A FINAL IN PECTION <br /> � SIGNED <br /> (DAW PLOT PLAN ON REV SE DE <br /> FOR DEPARTMENT USE—GAY <br /> PHASE I DATE ' <br /> fAPPLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> o PHASE I . GROUT INSPECTION PHASE III/FINALI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY e• DATE r. <br /> V U 1.1, <br />