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S' JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOk OFFICE USE: 1601ye% Hazelton Ave. , Stockton, Cal-*"of <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? a - 79 <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 CENSUS TRACT <br /> Owner's Name _G -u Phone <br /> Address CityTg d (n <br /> Contractor's Name(OM (Zr C_­,s s,-* `a License" Phone;�VS_ <br /> C <br /> TYPE OF WORK (Check) : NEW WELL /_ DEEPEN / RECONDITION /_7 DESTRUCTION /-] <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J <br /> Industrial _'Cable Tool Dia. of Well Excavation 1 <br /> Domestic/private Drilled Dia. of Well Casing / <br /> Domestic/public Driven Gauge of Casing <br /> ,Irrigation -Gravel Pack- - -Depth- of Grout Seal Lfzl <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface SealInstalledBy: <br /> PUMP INSTALLATION: Contractor ca_lr� cs.% !/Cses N S <br /> Type of Pump I, _ j n) H,p , <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /State Work Done <br /> )ESTRUCTION 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 /> JELL 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 INSPECTION <br /> 'RIOR TO GROUTING AtW,A FINAL IZSPE CT ION. � f ` <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n1 / <br /> kPPLICATION ACCEPTED B , ����s c �jG�-�!/ DATE <br /> kDDITIONAL COMMENTS: T <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> / <br /> I /77 91d <br />