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__ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFUS TCE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-,T97/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e11_/S/ 7,7 <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 i, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C.L CENSUS TRACT <br /> Owner's Name ,; C r- 0 Phone <br /> Address � <br /> City , 'C—&- <br /> Contractor's Name �-� �off, :.� License # Phone #, <br /> i� <br /> _ i <br /> TYPE OF WORK (Check) : , NEW WELL 'J / DEEPEN %/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY '�1• <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL va <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool `Dia. of Well Excavation �"� <br /> Domestic/private Drilled Dia. of-WeZ1 -Casing �- <br /> ^Dom�stc ublic <br /> %p Driven Gauge of Casing <br /> - Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout r <br /> Disposal Other Other Information i <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor N- p <br /> Type of Pump LL ini H,P. f n <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> I <br /> _ I <br /> PUMY '.REPAIR: / / State Work Done <br /> r <br /> i <br />)ES.TRUCTION 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 well, Il will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notifyethem 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 .GRO UT INSPECTION <br />'RIOR TO GROUTING AND_A FINAL INSPECTION. <br /> SIGNED (" ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE T �'. <br /> APPLICATION ACCEPTED ,BY - <br /> 1) TE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS IIl/F WL'INSPECTID <br /> INSPECTION BY DATE INSPECTION BY DATE S` <br /> 1077. _ 2M <br />