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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 16p1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:. (209) 466-6781 . 7�/4-� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �'Z•� <br /> t <br /> (Complete In Triplicate) j <br /> Application is hereby made tooaquin <br /> fftthe San Joaquin Local Health District far a permit to construct <br /> and/or install the work hereih described. This application is made in compliance with San J <br /> County Ordinance <br /> jNo�.Jy1'862 and! the Rules and Regulations of the .San .Joaquin Local Health District. ; <br /> ap 1 R ter? L� CENSUS TRACT j <br /> JOB ADDRESS/LOCATION �QVIP�144/Q II <br /> Owner's Name 6 ��� 1� L Phone <br /> Address 3�3rS �4-*ekd l Sege/ City ` <br /> 1111 <br /> �������� , � r License ll ��fhone <br /> Contractor's Name 5/0 o i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /-T <br /> PUMP INSTALLATION PUMP REPAIR Xr PUMP REPLACEMENT /� <br /> Other `/% <br /> Y, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i / PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED/USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> lndustr�al I Cable Tool Dia. of Well Excavation <br /> Domestic/private it Drilled Dia. of Well Casing V <br /> Domestic/public tl Driven Gauge of Casing ' <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I. Rotary Type of Grout <br /> Disposal ;1 Other Other Information �. <br /> Geophysical „_ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type tof Pump — H.P. <br /> 1 <br /> PUMP REPLACEMENT: / / jState Work Done <br /> Al <br /> PUMP REPAIR: ;'State Work Done <br /> Approximate Depth <br /> � DES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree tocomply 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 /> f information is true to the best of my knowled e and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO GRO TING AND A FINAL INSPECTION. <br /> j SIGNED ` TITLE . <br /> if go RA14 PLOT PLAN ON REVERSE SIDE <br /> FOR DEPAR NT USE ONLY <br /> PHASE I /�� DATE <br /> APPLICATION ACCEPTED :BY =r <br /> ADDITIONAL COMMENTS: pgnr:i,_I I r , aI INSPECT <br /> PHASE II GROUT INSPECTION �, > S SATE"fes, _ <br /> j INSPECTION BY ' DATE INSPECTION B <br /> 077 - 2M <br /> ' F N 1476 ao.,- . 1-74 �/ / � • Jv • <br />