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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�Jk'OFFICE USE: L 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> rmit No. 27 J, kJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <br /> (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.ZI862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �.� CENSUS TRACT <br /> Owner's Name i D 3 /� / /-�4 /✓d STN��i Pho e <br /> g�3 . <br /> Address City <br /> i <br /> Contractor's Name C.AL IV,, &0j I I&F C& License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION / / DESTRUCTION /_7 T <br /> PUMP INSTALLATION '/ / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> — — <br /> DISTANCE TO NEAREST: SEPTIC TANK 6j2_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD jP0 CESSPOOL/SEEPAGE PIT OTHER <br /> F ' PROPERTY LINE - PRIVATE DOMESTIC WELL ,PUBLIC. DOMESTIC WELL <br /> INTENDED-.USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS \ .� <br /> Industrial Cable Tool Dia. of Well Excavation y ' <br /> Domestic/private Drilled Dia. of Well Casing ^ occ�v rrb <br /> ..'Domestic/public Driven Gauge of Casing 0C 7z eW <br /> "Irrigation _ . 'Gravel Pack Depth of Grout Seal <br /> Cathodic Protection twwolotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor T =i �7`'"" <br /> H.P. <br /> Type of Pump a `` <br /> :. <br /> PUMP REPLACEMENT: / ./ State Work bone <br /> PUMP .REPAIR: / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter- / --� _ Approximate th <br /> Describe Materi 1 and Procedure <br /> --� ' <br /> I hereby agree to comply with all laws and iregulfations of the San Joaquin Local Health District <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:.,before putting the well in use. The above <br /> informationis ta to `the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO U Nr AN FINAL INSPECTION. <br /> SIGNE . TITLE <br /> 711 <br /> DRAW P T PLAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATIO EPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE II /FINAL INSPECTION <br /> y INSPECTION BY DATE INSPECTION BY DATE e� l_T <br /> E H 1426IRZ. 1-/4 � `5, X' �'`' 7 7 `�. � <br />