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SAN JOAQUIN� 'AL HEALTH DISTR- <br /> FOF OFFICE USE: 116..,i E. Hazelton Ave. , Stockton, uviif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-/136u <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Zr- 3_jS <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of, the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 � ( �' f 17 <br /> CENSUS TRACT <br /> Owner's Name ///j ' y� f Phone <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /% RECONDITION /� DESTRUCTION <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 - PRLVA^. 'gTd*ff " 1,4ELL PUBLIC DOMESTIC WELL p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <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 Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter / <br /> ,� � Approximate Depth 3 <br /> Describe Material and Procedure <br /> •�i�!?� <br /> I hereby agree to complf with all laws and regulations of the San Toaquin 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 INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> L / s� r� <br /> -_IDD TITLE <br /> AW PLOT PLAN ON REVERSE SIDE) <br /> FOR REPARTMENT USE ONLY <br /> PHASE I /1 <br /> APPLICATION ACCEPTED BY DATE b" - <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INtPECTION PHASE III F NAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE el —:412-15 ^ <br /> E H 1476 vo., 1_7/. I_ /,• •,,• <br />