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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP; OFFICE SE: 1.601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone: <br /> (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '17-13 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,/J '.a-f"Z% <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 P jj.t ,V g We _ CENSUyS TRACT <br /> Owner's Name N in w mc)k 1 # + Phone <br /> c,�+3 a, 3g.® <br /> Address A0 Q Y <br /> S x X. i Cit �J <br /> Contractor's Name0. eu, � tiy, �-L-ir-ense #.—M p Phone <br /> AZt <br /> TYPE OF WORK (Ch c.k) :�, NEW 1-WELL_�/ / DEEPEN / / RECONDITION:/�/ DESTRUCTION /7 _ <br /> ,i \ ; '? � sPUMPIINSTALLATION PUMP,REPAIR / / PUMP REPLACEMENT <br /> Other., <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES P.IT,}PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE "S'T <br /> PRIVATE DOME 'i0WELL —'_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic Q . <br /> /private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal CN <br /> Cathodic ion Rotary Type of Grout <br /> Other - - Qt_he.r_Ijaf,cLrmation <br /> at odic Protect <br /> Geophysical t4. , '- ,� � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor / • �_�.�1 �„ ,� �� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> J <br /> PUMP -.REPAIR: / / State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter y 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 DAY'S <br /> after completion of my work on a new well, I will:�:furrii-sh 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 1'O A GROUT INSPECTION <br /> PRIOR TO GROUZMG AND A nNAL4NSPECTION. <br /> SIGNED ' " TITLE " J <br /> (DRAW PLOT PLAN ON REVERSE SIDT-) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I/FINAL INSPECTION <br /> INSPECTION BY In _ DATE INSPECTION BYPUKDATE <br /> II <br />