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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _70T;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S:16 71 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby :nada 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 /> JOB ADDRESS/LOCATION j /J 2 <br /> �i `ems 4 CENSUS TRACT <br /> Owner's Name h S L 04es V 070d<` Phone 7a7 <br /> `Address City 4a4CQ <br /> Contractor's Name " ' License Phone <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN '/7 RECONDITION /7 DESTRUCTION /'7 <br /> PUMP INSTAL TION/ / PUMP REPA -/-7PUMF_ REPLACEMENT /7 <br /> Other 9/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 01 <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 i <br /> _ Domes-tic/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 <br /> _ By: ,_,.._.,... <br /> PUMP INSTALLATION-. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> E&TRUCTION_OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agreeto 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 GRO G AND A FINAL INSPECTION. 3 73._S <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR_DEPARTMENT USE ONLY <br /> 'PHASE I <br /> APPLICATION" ACCEPTED BY 1, DATE -7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT INSPECTION PHASE I i FINAL INSPECTION/ <br /> :INSPECTION BY _ DATE INSPECTION BY c DATE <br /> D,._. 1 '7A <br />