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(�Z� r! N JOAQUIN LOCAL HEALTH DISTRIC <br /> FOF OFFICE USE: 1607"E. Hazelton Ave. , Stockton, Calf . <br /> Telephone: (209) 466-678176- _�73U <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Permit No. . <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 /> JOB ADDRESS/LOCATION �' I(7 E Tr e e' ;,oye -%�DD ( 6 "",CENSUS TRACT <br /> r <br /> Owner's Name Jn �r-a S G/V/ 42 Phone 3> <br /> Address (� 3�� j��� !VA LI � L i� City <br /> Contractor's Name �`�-a� if/ s , , License # ' Phone' <br /> TYPE OF WORK (Check) : NEW WELLT/� DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INS LATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private ` X Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation �l Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout 57 m E N <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed E:-jLWK Wgi-I <br /> PUMP INSTALLATION: Contractor �- a <br /> Type of Pump - 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 /> ?RIOR TO GRO T NG 4ND A FINAL INSPECTION. <br /> SIGNED r -�- TITLEC../ -a_.rrs r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i= DATE <br /> ADDITIONAL COMMENTS: <br /> P E L;I QROUIVINSPECTIUN PHASE II3/FINAL INSPECTION <br /> INSPECTION BYDATE —�2 7TH INSPECTION BY DATE <br />