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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICY'USEi 1601 E. Hazelton Ave. , Stockton, Calif. c D <br /> Telephone : (20 9) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. x <br /> THIS PERMIT EXPIRES' 1 YEAR FROM DATE ISSUED . Date Issued/a--;2y-7 <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 /> zr2 . •.) k <br /> JOB ADDRESS/LOCATION ' vX ��� o� "°" >'" CENSUS TRACT 0/2- V""2�6 <br /> Owner's Name � _ JO �S -- - Phone <br /> Address' SSM P A-s' City # . <br /> K <br /> Contractor's Name W License Ila D <br /> Phone '74, <br /> TYPE OF WORK (Check) : NEW WELL /T DEEPEN _/ RECONDITION /_/ DESTRUCTION /µ] _ <br /> N PUMP INSTALLATION /PUMP REPAIR / { PUMP REPLACEMENT { / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKeo EWER LINES PIT PRIVY _ I <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 gable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing 115211 <br /> Do tic/public Driven Gauge of Casing <br /> rigation Gravel Pack Depth of Grout Seal W <br /> Cathodic Protection Rotary Type of Grout d <br /> Disposal. Other Other Information' < . <br /> Geophysical Surface'Seal Installed-B : ros <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �u� /a�:s�y�.. H.P. ZQ <br /> 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 of 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 iii 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 GROUTING AND A FINA INSPEC <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FI INSPECTION_„— <br /> INSPECTION-BY SATE INSPECTION BY DATE !i <br /> 0!77 2M <br /> F P IA9A Do . 1-7/1 <br />