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w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ?ad 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71 -mv <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedTT? <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONO CENSUS TRACT <br /> �1. I <br /> Owner's Name q Phone Fd.3— Z/ Q <br /> `"t l ! <br /> Address City - - <br /> Contractor's Name •�� 4�?f License �����IoPhon �, // <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN '/_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / J <br /> Aj <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER *LINES ',PIT PRIVY r <br /> SEWAGE DISPOSAL- FIELD- 1: CESSP0OL/8EEPAGE PIT OTHER <br /> r PROPERTY LINEr' 'PRIVATE:.DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout <br />—Disposal- Other Other Information ~�I <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Gontractor azd <br /> Type of Pump H. <br /> PUMP REPLACEMENT: State Worst Done � <br /> PUMP REPAIR: State Work Done n <br /> i <br /> DESTRUCTION OF WELL: Well Diameter # Approximate Depth <br /> Describe Mater1a1" nd ,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 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 is true to the best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TO �UTIN�GANAL INSP CTI N.SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY t <br /> PHASE I ' <br /> APPLICATION ACCEPTED .BY ` � DATE 7,11 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 4 aDATE INSPECTION BY DATE "-17�7 <br /> 2 U 7l�� n .. �_7i. IL7: � 2 1 <br />