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SAN JOAQUIN�-LOCAL HEALTH DISTRICT j r <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ► <br /> Telephone : (204) 466-6781 <br /> Permit No -7APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> 7 7-- -2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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/LOCATIONCENSUS TRACT <br /> Owners Name Phone Yv; 1r <br /> � 4 <br /> Address ` City <br /> Contractor's Name Q License Otffr oe Phone *7�i� <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ UMP REPAIR/ / PUMP REPLACEMENT -/� <br /> - T- - - .0 ther-/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD - IX CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation !./`/ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 3 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary '-Type of Grout <br /> Disposal Other `.Other Information 7 <br /> Geophysical -Surface Seal Installed BY: a&4ns <br /> PUMP INSTATION: Contractor <br /> .._. Type of Pump H.P. /u`" . <br /> fs <br /> {.1 <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 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 /> hWELL,rDRILLERS 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 INSPECTION <br /> PRIOR TO GROUTING D A F AL INSP CTIO ,-1 <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 141FINW INSPECTI N ' <br /> INSPECTION BY DATE N INSPECTION BY DAT .2 <br />} C65177 2M <br />