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M iG 7.0 Ow�v W"" <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT M <br /> FOE OFFICE USE: 1.601. E. Hazelton Ave . , Stockton, Calif. <br /> , Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-�1�C[� <br /> 77-/c1l�I° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1 <br /> JOB ADDRESS/LOCATIONngv Com-_ CENSUS TRACT <br /> '{ <br /> Owner's NameVii J l p _ Phone <br /> Address City <br /> I <br /> Contractor's Name License # Phone <br /> { <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION Al PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,!S- SEWER LINES -57-S/ 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 /> 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 /> PUPAk <br /> INSTALLATION: Con ac or7 0 ` �� T ��' r'� �'� o•� •f ��� <br /> Type of Pump t- _- _ --_-- <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> S-TRUCTION OF W LL- lameter <br /> escribe Material <br /> tl Of <br /> I hereby agree to co ply with all laws and regulations o the San oaquin 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 them before 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 GROUTINS7e D A FINAL INSPECTION. 1 <br /> SIGNEDTITLE ,I_ 1J _ i <br /> xuime <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -15 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Z;Ile 1'4� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE, I GRO T INSPECTIONP I/F INSPECT ON <br /> INSPECTION BY ATE r —7� INSPECTION BY DATE ? <br />