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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> Et?F_OFFICE USE: 3 601 E. Hazelton Ave. , ;Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT EXPIRES I.-YEAR FROM DATE ISSUED Date Issued ;Sz <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. 1$ 2 and tae Rul sand Regulations of the San Joaquin Local Health Dist#dt. <br /> JOB ADDRESS/LOCATION ©i SvV. A2 42 1 Seln <br /> NSUS TRACT <br /> owner's Name/ '� �5 ../x,� - _ Phone <br /> Address City <br /> t <br /> Contractor's Name �6 License J&,ZfZ y Phone ` <br /> i <br /> i <br /> �'TYPE-OF"WORK. :(Chdck) :ANEW ;'•WELIr-/' /."`DEEPEN-!/ /--:RECONDITION /-7.—DESTRUCTION / '• "" "`" �'� <br /> PUMP'INST�TION / / PUMP REPAIR / �I. _PUMP REPLACEMENT <br /> Other <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 SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11 <br /> Domestic/private ; . Drilled -Dia. of Well Casing �� <br /> Domestic/public Driven Gauge of Casing 40 C44 4. <br /> Irrigation Gravel Pack Depth of Grout Seal --� <br /> Cathodic Protection Rotary Type of'-=Grout 41, <br /> Disposal Other . Other Information <br /> Geophysical ` - 'Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type'. of Pump H.P. <br /> t PUMP REPLACEMENT: / / State 'Work Done \ <br /> PUMP ,REPAIR:. - -/.. / _State,'Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth .— <br /> Describe Material and Procedure <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 Iwell, I will furnish the San Joaquin Local Health District F <br /> WELL DRILLERS REPORT of the well and otify them before putting the -well in use. The above <br /> iniprmation is true to the be of m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T NG D A F NS ION. <br /> SIGNED TITLE dernc <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P IGROUT IN ECTION PHAS I / NAL IN PECTION <br /> INSPECTION BY DATE INSPECTION BY DATE. <br /> . Y _ 1177 2t <br /> c u ILg4 n __ 1_71. <br />