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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF OFFICE USE: ✓ ib01 E. Hazelton. Ave. , ;Stockton, Calif. <br /> v Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , <br /> t (Complete In Triplicate) <br /> Application is ` iereby 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 /> JOB ADDRESS/LOCATION 7 Lgka-KjzCENSUS TRACT <br /> Owner's Name _ : rUPr _ Phone <br /> Address city , ' <br /> Contractor's Nam License .9 O Phone 6 <br /> TY <br /> I'EOF�WORK-(Check): '°NEWTWELL�'% —DEEPEN�/ ND-ITION_/7�DESTRUCTION "� <br /> E PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT f? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW�ER LINES a PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD O' - CESSPOOL/SEEPAGE PITS 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 /> C---75omestic/private Drilled Dia. of Well Casing <br /> Domestic/public - Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sem <br /> Cathodic Protection l�Aotary Type of Grout g± � � ua <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B •. <br /> PUMP INSTALLATION: Contracto ° <br /> t. Type of Pum H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> State Work Done <br /> i PUMP .REPAIR: /f / _�, _�� <br /> DESTRUCTION OF WELL.: Diame 'er - - - r prox' ate Deptit <br /> k Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations oE.the San; JoaquiilfLocal Healthbistrict <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 Sanlioaquin Iocal Health District a <br /> WELL DRILLERS REPORT. of the well and notify- them-before-punting-the..well in `use..�The_above�v <br /> inform 'on is true to th knowledge and belief. I WILL°CALL: FORA GROUT INSPECTION <br /> , PRIOR TO TING AND A AL CT O <br /> SIGNED TITLE <br /> W <br /> PLOT PLAN ON REVERSE SID <br /> FOR DEP TMENT USE ONLY <br /> t� <br /> f PHAS r DATE <br /> APPLICAT.ION ACCEPTED,BY `.F �`` F'i _ - <br /> ADDITIONAL COMMENTS: A <br /> P S II/FI AL INSPECTION <br /> PHASE;�I� GROUT INSPECTION <br /> DATE / <br /> /-7y 'INSPECTION B DATF/0 <br /> INSPECTION BY. f <br /> R 14 11x26 Rev: 1-74 <br />