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j %",A' JOAQUIN LOCAL HEALTH DISTRICy.V <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 94i_ ,23 f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> nOB ADDRESS/LOCATION . <br /> Lr 1 /1 -'�%� f CENSUS TRACT <br /> kuner's Name ZE� /4, C ,; Phone <br /> Address 74116 S'a /,/ Cit S/ <br /> _.,ontractor's Name S�ar)c// ., , - J6; License N / 3 z Phone 2 -7.7 <br /> J <br /> CYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /—T DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR ITI PUMP REPLACEMENT /7 <br /> Other <br /> -OISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL S <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 <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 /> 'UMP INSTALLATION: Contractor <br /> Type of Pump u i in '•. H.P. �oG <br /> ''UMP REPLACEMENT: /_/ State Work Done <br /> UMP '.REPAIR: CKT State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ,,,nd 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 /> 'TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> .nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> `PRIOR TO GROUTING AND A FINAL INSPE I0N_.�\ <br /> SIGNED err. , '.�TITLE f� . <br /> (DFAW/PLOT PT AN ON REV SE SIDE) <br /> F ARTMENT USE ONLY <br /> PHASE I <br /> TPLICATION ACCEPTED BY 2 7V DATE <br /> ADDITIONAL COMMENTS: <br /> `NSPECTION BY <br /> PHASE II GROUT INSPECTION PHASE III/ 'INAL INSPECTION 7 <br /> DATE INSPECTION BY DATE <br />