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g 0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. ,7b_ $ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Sf2c�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7- 29-7G <br /> (Complete In Triplicate) <br /> Application is hereby made to the Scan Joaquin Local Health District far 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 �J �� CENSUS TRACT <br /> Owner's Name e /' l Phone <br /> Address i . �'/ u City®�'K r f' <br /> Contractor's Name t 3" d h License Phone?V �d <br /> TYPE OF WORK (Check): NEW WELL ,o DEEPEN CONDITION � DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/-7—pump REPLACEMENT 17 <br /> Other <br /> 'DISTANCE TO NEAREST: SEPTIC TANK ZZ d I SEWER LINES PIT PRIVY <br /> SEWAGE DISP69AE FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE 0 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> domestic/private �— Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 2. <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 B i <br /> PUMP INSTALLATION: . Contractor <br /> Type of Pump H.P, <br /> pUMP 'REPLACEMENT: / State Work Done <br /> PUMPIREPAIR: / / State Work Done <br /> { DES;TRUCTION 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 there before putting the..weil. 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 A FIN INS CTION. n <br /> SIGNED TITLE Q1 //7a°/' <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 2-Aj <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIQV P SX III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 75 2M _ <br />