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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 'OFFICE USE: 1601 E. Hazelton Ave. , , Stockton, Calif. <br /> Telephone: (209) 466-6781 ��/ / ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r6 j <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 131-71 <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:- Ige (�' � � CENSUS TRACT' <br /> Owner's+Name ` Phone <br /> Address <br /> City <br /> Contractor's Name V s License #J%C2Zkp�-Phone <br /> i <br /> r _ _ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION f_1 DESTRUCTION /_7 <br /> •t PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT / 7 <br /> i 'r�. !• Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � I <br /> i PROPERTY. LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r <br /> INTENDED USE t TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia, of Well Excavation <br /> i/'rpomestic/private t ? i/ Drilled Dia, of Well Casing. <br /> Domestic/public .f Driven Gauge of Casing <br /> Irrigation 3 Gravel Pack Depth of Grout Seal <br /> 4 j; <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal [ Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �-� <br /> Type hof Pump H.P.. <br /> F � <br /> i <br /> PUMP REPLACEMENT: - / / State Work Done <br /> i <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agxee 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 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 GROUTIINSPECTION <br /> PRIOR TO GROUTING A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY v" DATE &nL S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE, I/FIN INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> © � ' 1177 <br />