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SAN JOAQUIN LOCAL BVALtH DISTRICT <br /> FOAiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued��-7Za <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 trade 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 _ �6 / r el- CENSUS TRACT <br /> Owner's Name . /' Phone <br /> � lep <br /> City G d�l'1 <br /> Address �o�!' <br /> Contractor's Name 0 License Phon -a <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT `T <br /> AL <br /> other I I <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 /> D <br /> owestic/private Drilled Dia. of Well Casing <br /> ote stic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> E Disposal Other Other Information <br /> i Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I / State Work Done <br /> PUMP :REPAIR: I State Work Done e.,ow9rdx. e- r <br /> c <br /> .RES-TRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> I, Describe Material and Procedure <br /> jI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 3 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-be t.of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G 0 TIN A FINM/IUSPECTION. <br /> SIGNED TITLE Y <br /> k (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> PHASE I DATE Z2 Z7 <br /> APPLICATION ACCEPTED BY a' q e�- <br /> ADDITIONAL COMMENTS: <br /> P SE GROUT INSPECTION, FISAL INSPECTIO <br /> INSPECTION B—_'-=2 DATE INSPECTION BY DATE -3 /t, / <br /> r16 <br /> µR R 1,G.7h Ratr_ 1-7�r 1-74 2M <br />