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/W ° u JOAQUIN LOCAL HEALTH DISTRICT - <br /> OFFICE 'JSE: 160,.,.x:. Hazelton Ave. , Stockton, Cal...,. <br /> Telephone: (209) 466-6781 17 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -lam 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `� ed. CENSUS TRACT <br /> Owner's Name L A -JILE �lon 91 —77SQ <br /> Address Sig Yr► � City 2!�,Sc 19k 0-V <br /> Contractor's Name .7 11/_ Nr �6 c p License # O T).0-&Phone �J7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT % <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 WEI L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable-Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing r' <br /> Domestic/public Driven Gauge of Casing V <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 H.P. <br /> - c <br /> PUMP REPLACEMENT: State Work Done /ry p T n,• <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 0 <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 tqjhP__,best_o.f:. m}�kno dge._agd_.�elief� ._� WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI AND A FI IN PECTION. <br /> SIGNEDTI TLE <br /> 1-4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY >_A./f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GF.OUT INSPECTION PHAS)7III FIN INSPECTI N ' <br /> INSPECTION BY DATE INSPECTION BY .tet. DATE <br /> /V 411 <br /> - " 1 /77 W <br />