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f� SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> F0T­OFFICE USE: r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?Z-/ 1- <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <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 /> Count'}r- Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION ' 0 CENSUS TRACT <br /> 4; <br /> Owner's Name Phone �V/, - <br /> it <br /> Address City <br /> Contractor's NameLicense It-w— 3 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/} DEEPEN/% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION & PUMP REPAIR / / PUMP. REPLACEMENT /7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT'PRIVY <br /> I SEWAGE DISPOSA,,L,�IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINES PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> :INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well, Excavation fe <br /> - Domestic/private Drilled Dia.,of Well Casing <br /> Domestic/public Driven Gauge of Casing l� <br /> -,'Irrigation Gravel Pack Depth of Grout Seal S <br /> Cathodic Protection _ Rotary Type of Grout l <br /> Disposal Other Other Information 1 <br /> Geophysical Surface _Seal. Installed By: <br /> G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .._,.._._=-sc.�� h9�.si H.P. <br /> PUMP REPLACEMENT: . / / State Work D.ofiZ_ - <br /> PUMP .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 a new well, I will furnish the San Joaquin Local. Health District a <br /> WELL DRILLERS REPORT of�e w 1I and notify them before putting the -well in use. The above <br /> information is &the best ofledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO FINAL .IN EC N. /l <br /> SIGNED - ` ' -T - TITLES <br /> (DRAW PLOT-PLAN ON REVERSE SIDE) <br /> .FPR DEPART NT USE ONLY <br /> PHASE I - - � <br /> APPLICATION ACCEPTED BY DATE S� <br /> ADDITIONAL COMMENTS: <br /> PHA$E II GROUT INSPECTION PHASE III/FINAL INSPECTION i <br /> INSPECTION BY _ DATE INSPECTION BY DATE <br /> R N 1G7A ve., I_.7A �Z7.7 V :2m <br />