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C <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' '1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Q . <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> 7 <br /> ,I (Complete In Triplicate) <br /> Application is hereby i}ade to the San Joaquin Local Health District for a permit to construct <br /> j and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1 <br /> JOB ADDRESS/LOCATION OPICENSUS TRACT <br /> 111 <br /> Owner's Name Phone eS? 74) <br /> t <br /> Address !-:� I�f � City ����� <br /> Contractor's Name , p ,j�( _ License #� VS/Phone �`� <br /> n -- - <br /> ' TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /_/ DESTRUCTION /_7 _ <br /> PU~MPu�INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> j Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.- . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVAT-E---D0MESTI7C--WELL PUBLIC DOMESTIC WELL =_ <br /> INTENDED USE TYPE OF WELL ._� "i �: , .J CONSTRUCTION SPECIFICATIONS <br /> Industrial , ,, - Cable Tool Dia, of Well Excavation <br /> Domes.tic-Ip-'r-iva-te- = Drilled - -Dia. -of -Well Casing— <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysicalu c eal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type:lof Pump - : H.P. <br /> 40 <br /> PUMP REPLACEMENT:' / / State Work Done <br /> I <br /> PUMP .REPAIR: / State Work Done &ZeWQ A2 d&,X) <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> I hereby agree to comply with all Laws and regulations 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 /> 4 WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information i ue to the nest of my knowledge and belief. I WILL CALL FOR A GROU.T'IINSPECTION <br /> G PRIOR TO CR IN AND A �ZNAL WSPEgT,10N. <br /> SIGNEDTITLE ' /( "A) <br /> (DRAW PLOT PLAN ON REVERSE SIDE)'- <br /> FOR <br /> IDE)FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II^� i S TIO PHV FINAL NSPEC�TIONN� <br /> INSPECTION BY DATE INSPECTION BY 77 <br /> 6617 7 2M�` <br />