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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOES OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-,7a 9, <br /> ``PMIS 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 Joaqt <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION 1 � �, <`,u[/� CENSUS TRACT <br /> Owner's Name Phone <br /> Address f> :S c, City <br /> Contractor's Name �a n , (%�� License Phone ;;XT-24F,-24' <br /> TYPE OF WORK (Check) : NEW WELL /rT' DEEPEN /_7 RECONDITION /__7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /v/_PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _7l� SEWER LINE5 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _2jQ_l 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 /> =omestic/private 'Drilled Dia. of Well Casing t' <br /> Domestic <br /> /public Driven Gauge of of Casing <br /> Irrigation �~ Gravel Pack Depth of Grout Seal 7� <br /> Cathodic Protection Rotary Type of Grout 7 ,r f <br /> Disposal Other Other Information f <br /> Geophysical Surface Seal Installed By: �. 2,r. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /�/ yState Work'Done� <br /> DESTRUCTION OF WELL: Wel Diameter -�--- Approximate Depth <br /> Describe Material and Procedure ? <br /> I hereby agree to comply with all laws--anal--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 <br /> WELL DRILLERS_REPORT.,.of-the-well-and-notify them-befor� putting-tile Ve-!!min use:- The ab'ove- <br /> information is true to the best of my knowledge and belief.' ,I WILL-CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTING ANDA FINAL INSPECTION., <br /> SIGNED �;� k v> ~Y :t��S, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �2. - <br /> ADDITIONAL COMMENTS: <br /> PHA T INSPECTIOW PHASF, NAL INSPECTIO <br /> INSPECTION BY DATE _� INSPECTION BY DATE 7 <br />