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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQr, OFFICE ,SF �' 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 �a(7 _70 ; <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 <br /> the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' CJO! �.�lG uwA ! 17 CENSUS TRACT <br /> .� <br /> Owner's Name � .� � � [�_�..�.��-a--` - Phone <br /> Address2 L Z ♦ Sa Z City <br /> Contractor s Name License 0 Phone <br /> F <br /> TYPE OF WORK (Check) :. ' NEW WELL ./ / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT r OTHER O <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 µ. Depth of Grout Seal s <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal' Other Other Information <br /> Geophysical Surface Seal Installed Ii : <br /> 1 <br /> PUMP INSTALLATION: Contractor 1_2i:. VCl Fc _ <br /> Type of Pump %t i' _ H.P. -�'`y -- � <br />' PUMP REPLACEMENT: / / State Work Done <br /> PUNT REPAIR: / / State Work Done <br /> �. <br /> DESTRUCTION 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 n tify them before putting the well in use. . The above <br /> informatio s true to the b s of m knowledge and belief. I WILL CALL R A GROUT INSPECTION <br /> PRIOR TO TING A FIN E ION. <br /> SIGNEDTITLE <br /> 4 <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE <br />'i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION -PHASE III/FINAL INSPECTION �- <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> F H 1L96 12av_ . 1-71L _M <br />