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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> ` <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l9- <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/LOCATION 7 <br /> 41 <br /> of, CENSUS TRACT <br /> Owner's Name Mle 0 Phone <br /> Address <br /> S A City IESC i%z o <br /> Contractor's Name 7- D.' <br /> JU License Phone <br /> TYPE OF WORK (Check) : NEW WELL—/ /`,A)EEPEN �/ / RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR j, / PUMP REPLACEMENT <br /> Other 1/ / <br /> DISTANCE TO NEAREST: SEP,TICITANK SEWER LINES PIT PRIVY j <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 I <br /> Industrial Cable Tool Dia: of Well Excavation <br /> - Domest-i-e -iva-te,---_,� <br /> P <br /> Domestic public.-, kf ;_4 t Driven Gauge of-Easing w <br /> Irrigation i Gravel Pack Depth of Graut Sea'1 <br /> Cathodic Protection 1 Rotary Type of Groiit'yu 4 r <br /> Disposal Other Other Information j <br /> Geophysical Surface Seal By: <br /> PUMP INSTALLATION; _ Contfactor: A <br /> y— <br /> Type of Pump ..�% Ii.P. <br /> . <br /> 3 : <br /> PUMP REPLACEMENT:: `State W 6-ii'i Done x<, <br /> PUMP REPAIR: 10 State 'Work Done , m <br /> DESTRUCTION OF WELL: Well Diameter r. <br /> Approximate Depth <br /> Describe Material and Proceddre' <br /> I hereby agree to comply withiall 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 we11 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 AND A FI AL NSPECTION. <br /> SIGNED er.AXOATITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> OR DEPARTMENT: USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: } _Z3, <br /> PHASE II GROUT INSPECTION. PHAS /FIN INSPECTION <br />.INSPECTION BY DATE INSP.ECTION'BY DATE � til <br /> 3 <br /> N <br /> ;RE7_<H.-1426 P"!- _7i uA77 0" <br />