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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOFR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ft <br /> Y 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,7-gy_ 7 R' <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 9rdigrance No. 180,2 and",e�Rle d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> s <br /> Owner's Name71,q_-.�, Rumm1 Phone <br /> Address k,} City s <br /> Contractor's Name i License # D 7.7- /Phone <br /> j <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /� DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMPEREPAIR / / PUMP REPLACEMENT -/_ <br /> Other / / %1 --�-»- -- _ - —•. ;�1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS LIMES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE S OOL/SEEPAGE FIT OTHER <br /> PROPERTY LINE -_-PRIVAT DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> strialable Tool Dia, of Well Excavation,ydu <br /> mestic/private Drilled Dia, of Well Casingmestic/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 y <br /> Geophysical Surface*Seal Installed .By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 7 H.P. , <br /> s <br /> PUMP REPLACEMENT: <br /> State Work Dane <br /> f <br /> PUMP .REPAIR: / / State Work Done " `. <br /> 17ES,TRUCTION OF WELL: Well Diameter Approximate 'Depth <br /> Describe Material and-Procedure , <br /> I hereby agree-t-o comply-with all--ldws and regulations of the San Joaquin Local Health 'District <br /> And the State of California pertaining to or regulating well "construction. Within FIFTEEN DA7�S <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 of my knpwiedge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GR NG AND FIN . WNSPE ION. <br /> SIGNED ) TITLE , <br /> �)(�n <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F9A DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY tiDATE i/Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROU INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ? � INSPECTION BY DATE <br /> h � /77 _ 2M <br /> I R U 7/,7F, n,... i ��. <br />