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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� OFFICE USE: /4t4A 1601 E. Hazelton Ave. , Stockton, Calif. <br /> IM Telephone : (209) 466-6781 <br /> �I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> !M <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a� <br /> (Complete In Triplicate) 2-?-2 -- UZO-"20 <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 Rule a d Regulati fcyf he S Jo qul.n Local Health District. <br /> II w �• � } <br /> JOB ADDRESS/LOCAT CENSUS TRACT <br /> II <br /> Owner's Name Phone Z_'7-,3—34J>3j_ <br /> Address 4 -er Cit .' 1 <br /> Contractor s Name (!4 <br /> } �}� / <br /> �N - zip ✓ icense i�C�G© ,F� Phone <br /> z <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPS /% RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT— <br /> Other <br /> EPT <br /> 0 they LACEMEN <br /> DISTANCE'TO NEAREST---- PITSEPTIC TANK SEWER LINES PRIVY t� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER S <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE OF WELL0 CONSTiRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> IM Domestic/private Drilled Dia, of Well Casing <br /> .IM Domestic/public Driven Gauge of Casing <br /> i <br /> 11 Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> IMDisposal Other Other Information <br /> IM Geophysical Surface Seal_ Installed By: <br /> PUMPJINSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / --State Work Done <br /> PUMPIREPAIR: / / State Work Done F <br /> IN - <br /> DESTRUCTION OF WELL.: Well Diameter - Approximate Depth <br /> f� 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 ox 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 /> WELLI�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 t <br /> PRIOR TO GR UTING AN INAL INSPECTI N. <br /> SIGNED ' _ . TITLE <br /> �I DRAW PLOT PLAN ON REVERSE SIDE) - - <br /> �� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �,i�{�l' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I. /FINAL INSPECTION <br /> INSPECTION BY DATE /(/ INSPECTION BY DATE C,_72a Z29 <br /> r <br /> F ITT 1L')A ate., 1_7A 77 - ,PF4 <br />