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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: L 1601 E. Hazelton Ave, , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f sa61 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y' <br /> (Complete In Triplicate) <br /> Appl,ication ,is hereby made to the Son Joaquin Local health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with <br /> San Joaquin <br /> County' Ordinance No. 1862 and the Rules and Regulations. of the San -Joaquin Local Health District; <br /> JOB ADDRESS/LOCATION 6(4-57- /ad w4y /Z- CENSUS TRACT <br /> Owner's Name Phone 361r- <br /> Address l dgte,�y Z- City . 617/ <br /> Contractor's Name t <br /> . �. (.(� L L � u I P ff . License # A ? Phone �Z- <br /> a <br /> TYPE OF WORK (Check): NEW WELL '/Z' DEEPEN './7 . RECONDITION % f DESTRUCTION /7 ' <br /> PUMP INST LATION % / PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: ; SEPTIC TANK SEWER -LINES FIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER, <br /> INTENDED USE j <br /> PROPERTY LINE -- PRIVATE DOMESTIC IfWELI;'• " PUBLIC DOMESTIC WELL <br /> TYPE OF WELL t�� CONSTRUCTION SPECIFICATIONS <br /> l O <br /> Industria � Cable Tool'�i`' Dia. of Well Excavation ' <br /> Domestic r� <br /> /private _ Drilled ' Dia. of Well Casing <br /> Domestic/public � Driven 'Gauge of Casing ► <br /> Irrfgatian ' Gravel Pack Depth of Grout Seal ICathodic �i l3 <br /> Disposal Protection Rotary Other Type of Grout Cbf�lU7 C�l�Df.(, - <br /> Other Information ' <br /> Geophysical -Surface Seal Installed B : r. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PIE .REPAIR: /_ State Work Done " <br /> r <br /> DESTRUCTION OF WELL:. Well Diameter <br /> _---�—�— Approximates.Deptih' <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 I <br /> WELL DRILLERS REPORT of the well and notify them before putting.. ihe-Ao"ell in,use... .The above <br /> information is true t6-the-best-of- my knowledge and belief. I WILL---CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTI G AND A ' FINAL INSPECTION. <br /> SIGNED � 1 .. _ - --,---•--- - -- --. � _.- ._ � _•� m,,.r_ <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I- n ! <br /> APPLICATION ACCEPTED BY �Wlm DATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION PHASE III FI AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE - �J�' <br /> E H 1426 <br />