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( ;,F f �✓ Vv" � 'j JOAQUIN LOCAL HEALTH DISTRICT/— <br /> FOR.,OF ICE USE: 1601_.:. Hazelton Ave. , Stockton, Cali. . <br /> ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued X41.7 <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 p -_ _ �" :. CENSUS TRACT ' <br /> Owner's Name / Phone , <br /> # a �, <br /> Address Ai,41 � - -- - City ' ' <br /> Contractor's Name License # _L27, - Phone 2Lat, �7,� <br /> TYPE OF WORK "(Check.): NEW WELL -/-7 DEEPEN ,/-7RECONDITION %T DESTRUCTION f7 <br /> PUMP INSTALLATION ,/ / PUMP REPAIR -/-/7 Pump REPLACEMENT I T <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <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 Cable Tool Dia. of Well Excavation Q <br /> .k_ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing t <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protectiorni Rotary Type of Grout <br /> Disposal . Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor rte' rr- <br /> Type of Pump r7 a r11V1d0, H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP .REPAIR; / State Work Done f. . , <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 /> 4 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 /> ?RIOR TO GROUTING AND A FINAL P GTION. <br /> !� <br /> r.. t�t TITLE <br /> SIGNE <br /> (PILAW-PLOT PLAN W REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY !: DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II G N9 CTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 41 <br /> DATE INSPECTION BY r4� DATEin- <br /> r -- <br /> 4 IA <br /> r . . - <br />