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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF—OF,-'OFFICE USE: 1601 E. Hazelton Ave, ; Stockton, Calif. <br /> -Telephone:. (209) 466--6781 zz <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,71-1✓d---, <br /> THIS .PERMIT EXPIRES 1 YEAR :FROM DATE ISSUED Date Issued I� �7 <br /> (Complete. In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> E and/or install the work herein described. This .appli.cation i.s 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 . CENSUS TRACT <br /> Owner.'s- Name /yJ e /fJU Phone <br /> Address <br /> City Ia D /O G r/'1/'��I <br /> , <br /> Contractor's NameI <br /> o• <br /> - License # , y6 phone `7�fa S"��'3 7� <br /> i <br /> . i <br /> TYPE OF WORK (Check) : NEW WELL / ]' DEEPEN /_/ RECONDITION ./_/ DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /0Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT 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 /> L` Domestic/private Drilled Dia, of Well Casing (� ,V/ 1 <br /> Domestic/pub lie Driven Gauge of Casing 6 p OC v i <br /> Irrigation Gravel PackDepth of Grout Seal <br /> Cathodic Protection � - Rotary Type of Grout �yy , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 3p p <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws -and regulations of the San Joaquin Local Health Distract <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 beforjY"putti.ng. 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 FI INSP CTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN.;ON REVERSESIDE} //�� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BY r <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY , ..... f �� INSPECTION. BY DATE <br /> X26 _. <br /> E H <br />