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�+ a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> W.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7d- .y tJ <br /> -76 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued LnZ 21 <br /> (Complete In Triplicate) 9 ' <br /> Application is hereby made to the Son Joaquin Local Health District for a permit t6 Construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquini <br /> County Ordinance No. 18b and,'the idea and Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATIO ' r'CENSUS TRACT <br /> . 6L <br /> Owner's Na Phone <br /> Address <br /> /d✓.�-z.�• Cita <br /> � <br /> Contractor's Name License 0 4hone <br /> TYPE OF WORK (Check): NEW WELL/ , DEEPEN 17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR `—PL1M}' REPLACEMENT I f <br /> / �Q� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ^, SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r1� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATION ,/ <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 /> Geoh sicalSurface Seal Installed 'B : <br /> P y <br /> PUMP INSTALLATION: Contractor _ <br /> Type .of Pump -. . H.P. l <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> 1-7 <br /> PUMP :REPAIR: 'State Work Done <br /> .PES TRUCTION. OF WELL: Well Diameter - Approximate Depth <br /> k 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 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 GROUTING AND A FINAL INSPECTION. . TITLE <br /> SIGNED <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .f <br /> APPLICATION' ACCEPTED BY �` DATE 'G/- �I 7& - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION F <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> fM <br /> A R 1494. ito,r_ ]_y4 <br />