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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> EOR OFFICE USE law 1601 E'. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION R WELL C N R TION OR PUMP PERMIT Permit No. J <br /> THIS PERMIT�MIRES 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 /> ou ty Ordina ce No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> N7 fADDRESS .00A ON CENSUS TRACT <br /> Owner's Name Phone <br /> Address �d ��Js97 City <br /> Contractor's Name IVA kj&nA Vj Licensee14 <br /> �3 Phon J <br /> i <br />` TYPE OF WORK (Check) : NEW WELL DEEPEN / j RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / J PUMP-REPAIR / / PUMP REPLACEMENT /7 <br />' Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRVVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE, PIT OTHER <br /> a •: :.?., <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL . . <br /> F INTENDED USE TYPE OF WELL F CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool Dia, of, Well Exavat3ion _u2 `-, <br /> Domestic/private Drilled Dia. ;of• ;We11 Casing N <br /> Domestic/public Driven .Gauge .'of" Casing O <br /> Irrigation Gravel Pack' f' Depfh",�of !Gto'ut Seal _ <br /> Cathodic Protection Rotary „Type bf Grout �,Q _- <br /> Disposal Other 10ther Information• r <br /> Geophysical S24rface Seal Installed B . <br /> PUMP INSTALLATION; C Crt-,4_— <br /> TYPe of Pump H.P. <br /> ! PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:: State-Work Done - -� - <br /> DES-TRUCTION OF WELL: Well Diameter ' - � _ "4 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 <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,4,J( --GROUT NG AND A FINAL INSPE ION. i <br /> t,SIGNEDY:', TITLE (9lu�'"�ng�r" - <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I '• <br /> 7 ry <br /> '.APPLICATION ACCEPTED BY DATE -� '7 <br /> tADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> tINSPECTION BY DATE INSPECTION BY DATE <br /> 7 77 2M <br /> F N 1L.9h V? I_7L <br />