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F JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601 Hazelton Ave. , .Stockton, Cal_ . <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 S 35 77 <br /> (Complete In Triplicate) <br /> Tpplication is tereby 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 Joaquic <br /> Dunty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION z(jy/iij L, (_/1M S L(il'/f CENSUS TRACT <br /> ..+per's Name MA1� G � � G //�/_" Q Phone <br /> 1dress ;Z0 ZC) 1, L,6>M S %O G,[( CityJL- <br /> Contractor's Name � ' /� L� License # ;LLOZ Phone 2:KZ- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <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 <br /> Domestic/private Drilled Dia. of Well Casing (� <br /> Domestic/public Driven Gauge of Casing 2SQ <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 /> POMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> .JMP REPLACEMENT: / / State Work Done <br /> JMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> T 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 /> [ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> "ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information s true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> :IOR TO G NG D A IF AL INSPECTION. <br /> ..,CGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> {ASE I <br /> APPLICATION ACCEPTED BY IrI9 DATES- <br /> 'ODITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA S I/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY — DATE / 7 <br />