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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> —f-0--h.—OFFICE USE: 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 Datie .I'seued <br /> (Complete In Triplicate) ` <br /> Application i6 hereby made to the San Joaquin Local Health District for a perm' ' construct <br /> and/or install the work herein described. This application is made in compliance- raith San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION 167,06 5 . C.)� �.e,r 1��, CENSUS TRACT <br /> Owner's Name t--A r Phone 1 3,r- '7 1-7 fc <br /> Address + /� <br /> City i��c�- <br /> Contractor's Name d S o,n. J D ;� �a License # 916i-L. Phone -0?- 3 95-6 <br /> TYPE OF WORK (Check): NEW WELL.,/-7 DEEPEN '/-7 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 /> 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 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 Depth of Grout Sear. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor A).4, � <br /> Type of Pump / r2 r r i1 - D': H.P. <br /> PUMP REPLACEMENT: . /7 State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 notify Chem before putting. the.well in.use.... .The above <br /> information is true to the-best o€- my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE ;- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -Z 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P4ggIIjVj'TINAt INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE Q <br /> II <br /> P-9 <br />