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p r <br /> !a" r' /' ' ' N JOAQUIN LOCAL HEALTH DISTRICT <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. JJ-S.S$I' <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION loo L f -/TGc c-/ ! o n o f CENSUS TRACT <br /> Owner's Name LT't, Art <br /> Da hA. re, Phone / <br /> Address !da L S 7-4e-,A: zein 0 City <br /> Contractor's Name �� _1. t/ s""r 1 � License 11 L13--Fhone cu, 7L 76 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-] <br /> PUMP INSTLATION REPAIR &7 PUMP REPLACEMENT /7 <br /> AL <br /> Other / / <br /> DISTANCE 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> Industrial Cable Tool Dia. of Well Excavation o� <br /> Domestic/private Drilled Dia. of Well Casing N <br /> Domestic/public Driven Gauge of Casing <br /> �c Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal InstalledBv: 2 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 4 -L ' <br /> PUMP REPLACEMENT: / / State Work Done �. <br /> PUMP .REPAIR: State Work Done (:" .•c-, �c.+ 0.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 /> 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 knpwle ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINGAND A FI AL INSPE <br /> SIGNED E <br /> (DRAW 0 PLAN ON REVS IDE) <br /> 0 EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / /[t P✓ //!"C' G i _ DATE j-IC 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE S� <br />