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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "7-7- 79,3GG <br /> THIS PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED Date Issued `/ <br /> k <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. <br /> JOB ADDRESS/LOCATION © ityZo�tiG e CENSUS TRACT <br /> Owner's Name 41-1GQ r'1' � Phone ,3"- 926 r-__ <br /> Address City G-d <br /> Contractor's Name . �9 ��rnp-� (![[ �,//ji«i License Phone 2tf=3 Z;�� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/CONDITION /_7 DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES 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 Z,_­Cable Tool Dia. of Well Excavation <br /> /' Domestic/private Drilled Dia, of Well Casing ell <br /> Domestic/public Driven Gauge of Casing G� <br /> Irrigation', Gravel. Pack Depth of Grodt Seal <br /> Cathodic•Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> TyZoump H.P. <br /> PUMP REPLACEMENT: / e Work Done <br /> PUMP REPAIR / / State Work Done- <br /> DES•TRUCTION_OF -WELL Well Diameter Approximate Depth <br /> Describe Material and Procedure _ <br /> I hereby agree to complywith all laws and regulations of the San .Joa.quin 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 <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 INSPECTIO <br /> PRIOR TO GROUTIN MP A NAL C <br /> SIGNED TITLE -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTT9N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY A.-7,/ DATE./} <br /> 6/7.7 _ 2M <br />