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v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F01w OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.17 <br /> �- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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. 1 6 Ind, thRules and Regulations of the San Joy�q�in Local Health District. <br /> /i Ot- <br /> JOBADDRESS/LOCATION J� A,f 7b CENSUS TRACT <br /> 'V <br /> Owner's NameElem6 �s,3 <br /> f R Phone <br /> Address .Lep. City <br /> Contractor's Name (l License #111211- Phon <br /> X <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /� I � <br /> Other / / — " <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER. & P10 7Qt,�. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLM-4" 64oxhAs <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation _ <br /> `'Domestic/private Drilled Dia. of Well Casing �u <br /> Domestic/public Driven Gauge of Casing 114?0°4 <br /> Irrigation Gravel Pack Depth of Grout Seal MevA p< 1"O'Ce <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor (� <br /> Type of Pumpr&A4 <br /> H.P. ZT i <br /> PUMP REPLACEMENT: / / State Work Done ? <br /> PUMP .REPAIR: / / State Work Done <br /> a <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 the well in use. The above j <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 NG AND A FINAL INSPECTION. <br /> SIGNED , TITLE , , d� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DE TMENT USE ONLY <br /> i <br /> PHASE I Xn <br /> APPLICATION ACCEPTED BY ' DATE <br /> ADDITIONAL COMMENTS: J <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 3 <br /> R u IL9A De I_7 J. 1777 9m 1 <br />