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F : <br /> O V11"SAN JOAQUIN L0tEA1-TH DISTRICT <br /> FOh.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ sa p <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <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 nd the Rul and Regulations of San Joaquin Local Health District. <br /> � g <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Name Phone <br /> Address Lj_ a . Cit ` <br /> Y ��1313 cti.-, .. ...,__ <br /> Contractor's Name ; License # Phone 5 H- 3 YS (o <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/�/ RECONDITION /_/ DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION � PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing V <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal g' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical V Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor : . + 10 c� <br /> Type of Pump SAM&, T� i 6.�. H.P. 1( 0 <br /> PUMP REPLACEMENT: / / State Work Done ' tr ) <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 /> 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 INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE �, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) L @.,.. __,.._. + <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -�iS-�� <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION P II/F AL NSPECTIO <br /> INSPECTION BY DATE INSPECTIONB DATE <br /> It I F H IL9A Da„ �_�/, 1/77 _ 2M r <br />