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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> FOkI <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued./7 + <br /> (Complete In Triplicate) <br /> Application is h 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 Joaquinj <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Jo quin Local Health District. <br /> JOB ADDRESS/LOCATION ✓`�4/ CENSUS TRACT <br /> Owner's Name f"71r& P")-, ^P. Phone <br /> Address eke /JD . C:� /�t.a City <br /> Contractor's Name License Phone sj - � <br /> i <br /> z <br /> TYPE OF WORK (Check) : NEW WELL�DEEPEN / / RECONDITION /—[ DESTRUCTION /_ s <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 — — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL __ PUBLIC DOMESTIC WELL �. <br /> INTENDED USE - TYPE OF .WELL CONSTRUCTION SPECIFICATIONp <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing \ <br /> �Dome.stic/publ�:c, T Driven Gauge_of. Casing 4 V <br /> Irrigation Gravel Pack Depth of G t 3ea1 ti\ <br /> Cathodic Protection Rotary Type of Grout <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 j <br /> DESTRUCTION OF WELL: Well Diameter ;;,'Approximate Depth 4 <br /> Describe Material and Procedure <br /> if s� <br /> I hereby agree to comply with all laws and regulations of the Sari Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'cofistruction. Within FIFTEEN DAYS i <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 Js t to he bestof my knowledge and belief. I WILL CAL R A GROUT INSPECTION <br /> PRIOR TO D <br /> INNSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 11101-7 <br /> ADDITIONAL COMMENTS: _ <br /> PHASGRO T INSPECTION P S /FINAL NSPE TION <br /> INSPECTION BY DATE INSPECTION BY. ' AT <br /> rr� - d frn�7.7 2M <br /> F. H I LL-9A P-7 . I�74 �� <br />