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N, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , _ ,x <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (�' (Complete In Triplicate) <br /> Application is hereby de 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 91 q -f.4X_r.01J C.V �a ENSUS TRACT <br /> Owner's Name e L 4 Phone ) <br /> Address �i � �"7 h �G A City <br /> •^ t <br /> Contractor's Name _ _ F,,[ /./ �' ��j�0S'"" y�(?jZ License # Q0 ho d' I Q� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN %/ RECONDITION /_/ DESTRUCTION` /7 <br /> PUMP INSTALLATI.ON / / PUMP REPAIR / / PUMP REPLACEMENT �/� � <br /> Other <br /> .DISTANCE.TO NEAREST: .SEP.TI.0_.TANK_. 4 SEWER-LIJ,E •(,1r(— =PIT PRIVY ' ="`"'. ` "— <br /> SEWAGE DISPOSAL FIELD QQ .T CESSPOOL/SEEPAGE-PTT OTHER <br /> �Y <br /> PROPERTY LINE - PRIU,?,TE DOMES TIC*'�WELL PUBLIC DOMESTIC WELI,----;-• N <br /> INTENDED USE TYPE OF WELL - 1 i. ` CONSTRUCTION SPECIFTCAT,1ONS""�`-�- <br /> Industrial Cable Tool Dia, of Wel1j Excavationes <br /> Domestic/private Drilled Dia. of Well Casing � +�' <br /> i <br /> -Domestic/public .. .Driven Gauge-of Casin I<T - <br /> FIrrigation Gravel Pack Depth of Grout Seal fit} t f 1_�1 <br /> _-._ Caithodic Protection 1 ..r'Rotaky Type of Grout <br /> D.i'sposal 1. [ Other Other Information s i0 y OGc�it/� <br /> _Geophysical. Surface Seal InstalledBY° . &___ <br /> P 4P INSTALLATION: Contractor <br /> Type of Pump I k� ',X, <br /> f /,/ H.P. 1 <br /> PUK? REPLACEMENT: . / / State Work Done �. t <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION -OF WELL: Ce-scr-iUU'Raterial <br /> ell. Diameter _A .f��� -�i"� / _ �App�roxim°ate Depth O7 <br /> T and Procedure' <br /> I hereby agree to comply with all laws and re' ulations*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 wiA,Jfurnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify themlbefore 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 .,GROAIyGANDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ! <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> 77 APPLICATION ACCEPTED BY i- DATE �! <br /> ADDITI.ONAI:-COMMENTS: <br /> ` <br /> PHASE II GROUT I SPECTIO PHASE J&FIN4 INSPECTION <br /> INSPECTION BY ,� ATE INSPECTION BY ATE l <br /> �_ 717 2M <br />