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SAN JOAQUIN LOCAL HEALTH DISTRICT M <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. A-60 7 a <br /> i <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 San Joaquin !; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joys}n Local Health District. <br /> JOB ADDRESS/LOCATION l CENSUS TRACT Y <br /> Owner's Name Phone S�i qL Z j/'L.4 <br /> Address Q` ,� City <br /> Contractor's Name Ca �:' f- CU License # hone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /? DESTRUCTION /_7 t� <br /> PUMP INSTALLATION / / PUMP REPAIR -/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES 100, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD rir�' CESSPOOL/SEEPAGE PIT OTHER — <br /> PROPERTY LINE PRIVATE DOMESTIC WELL f' 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 r <br /> Irrigation Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout , <br /> Disposal r Other Other InformationNo 6 <br /> Geophysical Surface Seal Installed B : Qt <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump `. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: <br /> . State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r . - Approximatie 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 DAIS <br /> will furnish the San Joaquin Local Health Distri"t a <br /> after completion of my work on a new well, I-: <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 i <br /> PRIOR TO GRO G AND a FIN NSPECTION. <br /> SIGNED k... ; <br /> TITLE <br /> (DRAWOMT PLAN ON REVERSE SIDE) <br /> FOR DEPA T T SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY v ` DATE <br /> &/ 7 <br /> � <br /> ADDITIONAL'COMMENTS:- <br /> PHASE II GROUT INSPECTION/ PHASE III/FINAL INSPECTION <br /> INSPECTION BY DAT A� VjW_CTIO BYDATE <br /> F. �9r, n�.. _7 i. 1i1 K/0 4 . N <br />