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i <br /> - SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> *FOR OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466-6781 u <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'�7--3(� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) I� <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. 1862 and the Rules and Regulations of the San Joaquin Local Health bistr�ct. <br /> JOB ADDRESS/LOCATION ; F ¢ 6 CENSUS TRACT 2`FS r[oo-Z <br /> ,yao ' of 2d , <br /> Owner's Name VNE Phone - L/[ - 3p fn <br /> Address City If i <br /> Contractor's Name <br /> it I License .. Phone egg <br />'TYPE OF7WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_7 DESTRUCTION /_7 i <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /? <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/StEPAGE PIT OTHER �M <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I <br /> r Cable Tool Dia, of Well Excavation• <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 4 <br /> i <br /> Irrigation Gravel Pack Depth of Grout Seal — <br /> Cathodic P"ro.teCtion Rotary Type of Grout <br /> I <br /> Disposal Other Other Information <br /> _Geophysical Surface Seal Installed101 <br /> B <br /> VU INSTALLATION: Contractor 2"`� Al <br /> /1�c.v <br /> i <br /> = Type of Pump - H.P. ' <br /> �--- <br /> PESMP REPLACEMENT: State Work Done t <br /> PUMA' .REPAIR: / /. State Work Done y 3jF <br /> DES:rWCTION OF WELL: Well Diameter <br /> Approximate-Depth..: ]V <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 i <br /> WELL DRILLERS REPORT of the well and notify there before putting the -well in .use. The above <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOit'"A GROUT INSPECTION <br /> PRIOR TO GRO TI G "AND INAL INSPECTION. <br /> SIGNED'' TITLE Y �! <br /> -�� <br /> PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTM_T.USE ONLY ,_ - - - <br /> PHASE I - <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION ~ PHASE FINA16 INSPECTION <br /> INSPECTION BY DATE f � ' INSPCCTION BY DATE <br /> - <br /> ,r: <br /> E H 1496 1177 air y <br />