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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh;ZFF-ICE USE: .f. <br /> 1601 E. Hazelton Ave.;) . 466-6781 Stockton, Calif. <br /> 9 <br /> Telephone : (20 ) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-,2/ 7� <br /> F [ (Complete In Triplicate) <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION u� S &0,44-0EAWCENSUS TRACT I <br /> _.. .� - <br /> Owner's Name <br /> Phone <br /> i <br /> Address City p <br /> Contractor's Name /} a►�y�j�} CO. License # Phe15� � <br /> 48 <br /> U <br /> Z <br /> TYPE OF WORK (Check) : NEW WE L AL/ / DEEPEN/% RECONDITION f-1 DESTRUCTION / <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMER—7 <br /> Other Y — " <br /> ! / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , ti <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER "*j ` <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4 ,I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of .Casi.ng <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection { Rotary Type of Grout <br /> Disposal Other Other Information ? <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor Y 't <br /> Type of Pump <br /> H.P. � <br /> PUMP REPLACEMENT: / / State Work Done .r►7 3 ld . j�/G`/fS W/�� <br /> PUMP 'REPAIR: <br /> State Work Done if_ �� &Ixeool, Cee aMdV/ (t$1+ i <br /> DESTRUCTION OF WELL: Well Diameter 1,/1 <br /> / 1"d" S Approximate Depth lodt7Kt;5' <br /> De cribe Material and Procedure tea,,, <br /> S�.f � r i <br /> I hereby agree to comply with all laws and regulations of the San Jpaquin Local Health District i <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DATS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri�ta <br /> WELL DRILLERS REPORT of the well and notify them before puDting 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 TING D FINAL INSPECTION. <br /> SIGNED TITLE <br /> 1 {DRAW PLOT PLAN ON REVERSE SIDE) �— <br /> FOR DEPARTMENT USE ONLY I. <br /> PHASE I , r <br /> APPLICATION ACCEPTED BY DATE 7S <br /> ADDITIONAL COMMENTS: .p e B w is IS <br /> PHASE II GROUT INSPECTION PHASE Z/FINAL INSPECTION <br /> INSPECTION BY D4TE INSPECTION BY <br /> E H 1426 ev. -74 woo --fICle, .�&�(:�77 2M � <br />