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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 "OF I•CE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS <br /> PERMIT EXPIRES .l YEAR FROM DATE ISSUED Date Issued 3 P-7 <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 din compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> S� ,i Q��tl I, <br /> JOB ADDRESS/LOCATION a.'�. Z � �®'" CENSUS TRACT ' <br /> Owner's Name ✓CS�z�� r� fi"�� Phone <br /> Address � � gy/ �i L� II City c.� . <br /> Contractor's Name License # /J -q1 hone "74 <br /> I <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN /�/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / _I PUMP REPAIR / / PUMPREPLACEMENT <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 <br /> f Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal_ Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � 4 <br /> w +l2e tea r� H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / State Work Done 7k .4 d. �` ✓ '� `X <br /> PUMP .REPAIR• / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter I 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 /> i 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 now -dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO R TING AND A F PEC I N.` <br /> . SIGNE ITLE @ ` <br /> RAW I.Q PLAN ON R . It SE <br /> S IDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I/ INAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE S <br /> x/77 _ 2M <br />