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SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> FOE <br /> ° 'OrFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 9-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is''Aereby 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 Josqu <br /> and Regulations of the San Joaquin Local Health District <br /> County Ordinance No. 1862 and the.Rules <br /> X CENSUS TRACT __ .T <br /> JOB ADDRESS/LOCATION '] SZOO <br /> . Phone <br /> Owner's Name '7`c>iLG% S i /Ya -Pelf <br /> C1C <br /> Address SCO O N� �'" � �z y <br /> License # 3&?o.i Phone <br /> Contractor's Name �� s�� a Yt 9 � Smt <br /> DESTRUCTION /7 <br /> TYPE OF WORK (Ch#ck) . NEW WELL J� DEEPEN /7RECONDITION / T <br /> PUMP INSTALLA IT ON /. J• PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other t/ / <br /> j DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT' r OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> j SPECIFICATIONS <br /> INTENDED USE TYPE OF.WELL CONSTRUCTION <br /> j -Industrial - _;7 - Cable-Too1 —Dia:- of Weli Excavation'f <br /> Industrial <br /> Drilled Dia. of Well Casing <br /> DomeDriven Gauge of' Ca'sing <br /> I Domestic/public - <br /> Irrigation R; -- -=7- lGrave-l-P•ack�- - of-vf Grout-Sea3 <br /> Rotar _ .,-;3,--Type'bf' Giout <br /> Cathodic protection. Other Information <br /> Disposal f ;,.6..+ Y � Other <br /> Geophysical ` .� 41_. Surface Seal Installed Bv: <br /> PUMP INSTALLATIONe CpAractor H, " <br /> ' Type iof Pump 1V4?JG <br /> ' PUMP REPLACEMENT: State WoDone t'+a^ <br /> Work F <br /> P <br /> PUMP 'REPAIR: 1 /-7 State Work-Done <br /> - - _ - / <br /> Approximate Depth <br /> I DESTRUCTION OF WELLS Well Diameter <br /> Describe Material and Procedure <br /> T ,. <br /> I hereby agree to comply with all' lawe., and regulatio:ts of the San Joaquin Local `Heelth iatri <br /> and the State of Calif ornia',pertaining to. or,regulating well'construction: Within FIFTEEN DA <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri <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 INSPECTI <br /> PRIOR TO GRO TING'•AND A' F NAL 'INSPECTION. � <br /> TITLE fr'to <br /> SIGNED DRAW PLOT PLAN ON REVERSE SIDE) <br /> ..EP HENT USE ONLY <br /> - t <br /> FO u�.�n. - USE <br /> I ! p �� DATE g <br /> APPLICATION ACCEPTED SY' ' <br /> ADDITIONAL COMMENTS:' <br /> PPHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> DATE INSPECTION BY <br /> DATE ' <br /> INSPECTION BY �_ �- <br /> 1fZ7 _. ' i <br />