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SAN JOAQUIN LOCAL- HEALTH DISTRICT F <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 rmit No. �7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pe <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /- Z <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for A permit to construct <br /> and/b r install the work herein described. This application� is made in compliance with San Joaquin <br /> County Ordinance No. 1.$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /72/ 3 F"/R C•,►Cz CGS— X2 ��� - - -- CENSUS TRACT <br /> Owner's Name / ,,,a Phone �� <br /> � <br /> 4 <br /> Address 2 "k­ cY City _ <br /> >' License # 7 hone <br /> Contractor's Name -e kt.�...e.. C l i a <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION /7 DESTRUCTION /7 ,7 <br /> AL <br /> PUMP INS LATION / / PUMP REPAIR / / PUMP REPLACEMENT / \ <br /> Other <br /> DISTANCE, TO NEAREST: ;_,,SEPTIC TAMC SEWER LINES 7 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT -mo-. OTHER <br /> PROPERTY LINFj RIVATE DOMESTIC WELL )jP— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 1 jr Domestic/private -- Drilled Dia. of Well Casing '• 1+ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack _ Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout n <br /> Disposal. Other Other -Information <br /> Geophysical Surface Seal Installed B lE -•. /�� <br /> PUMP INSTALLATION: Contractor_ =_/(/ '` rf <br /> Type of Pump '�+�. �, H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Jc! quin Local Health District <br /> and the State of California pertaining to or regulating wel•1 o struction.. .,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 /> f information is true to the best of my knowledge and belief. 1 WILL CALL FURCA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN PECTION. .ter----- -= ^^ "-~.• <br /> SIGNED _TITLE .. z <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY '4 t <br /> PHASE I �.�` I rA~q <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONALCOMMENTS'.T_�� <br /> �P II GR T INSPECTION y s '-� ;p S II/FIN INSPECTION <br /> INSPEC ibiN'B DATE /�-" ,. _ INSPECTION BY DATE �^ <br />