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SJOAQUIN FOCAL HEALTH DISTRIC <br /> FOE OFFICE USE: 160' Hazelton.Ave . , Stockton, Ca <br /> Telephone : (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7-7-?J9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Ti-LZ7 <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 Joaquir. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4 <br /> CENSUS TRACT <br /> Owner's Name hip / 1 .-• <br /> Phone <br /> Address Q 9 <br /> City <br /> Contractor's Name License ftel'Phon <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /CONDITION / / DESTRUCTION / 7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. PITPRIVY <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 �t. Cable Tool Dia. of Well Excavation Jfe��—"- <br /> Domestic/private Drilled Dia. of Well. Casing et <br /> Domestic/public Driven Gauge of Casing -� <br /> irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �-- <br /> Disposal Other Other Information Oi <br /> Geophysical Surface Seal lnstalled B : <br /> PUMP INSTALLATION: Contractor _Zr, <br /> Type of Pump 1c _-- H.P. _Yd <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 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 INSPECTl N <br /> PRIOR TO GROUTI G AND FIN INVECTION. <br /> SIGNED TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I - <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r7 <br /> - DATE ! <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECT ION. .BY:._ . DATE/,: j <br /> F N 1L26 T7pz, �_�� /.� d �' i mac,. <br /> ____ '. �,�77 _ 2M <br />