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_ P'N JOAQUIN LOCAL HEALTH DISTRIC" <br /> FOF OFFICE USE: 160 .. . Hazelton Ave. , Stockton, Calms. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, .7 2-10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/Z//7;7 <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 /> JOB ADDRESS/LOCATIONA&"L&s/!! sl �onF Q�EFrte. ggA_q CENSUS TRACT <br /> Owner's Name J/ M Phone C 6,'1 - Iy l <br /> Address 3f,3S Zf- Mo/t'1' S% _ City 57F4 <br /> 2'ory <br /> Contractor's Name 11&1u'//7fh/ iDUjy�2 ✓ .f'[Aj�1,47y jAwr, License 112617Afl Phon j�W <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION /e,- PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEWER LINES ,py r PIT PRIVY <br /> SEWAGE DISP SO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/W PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS u <br /> Industrial Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 3 <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump S - t � iib /� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Z <br /> APPLICATION ACCEPTED BY DATE �16:2 <br /> ADDITIONAL COMMENTS: CIAX C41 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 <br /> R u lb9f, ne., 1_74 b/77 _ 2M <br />