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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F01 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. l� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7;7-13 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedt/O <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and u'Regulations <br /> ssJof the San Joaquin Local Health District. <br /> JOB ADDRESS/� "! r Cl � /plfe CENSUS TRACT <br /> Owner's Name Q4,iit V Phone <br /> Address - lC City <br /> Contractor's Name t ��f<7 S �jt/ -� License /4��Phone <br /> TYPE OF WORK (Check) : NEW WELL / ION _DEEP N / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INST LATPUMP REPAIR / / PUMP REPLACEMENT­ /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK,5-6 4 SEWER LINES 71--;PIT PRIVY <br /> SEWAGE DISPOSALFIELD CESSPOOL/SEEPAGE PIT f Q!J f-OTHER" <br /> PROPERTY LINE/- 'k'RIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL - -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 4211Q <br /> j� Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven 'Gauge of Casing <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 Byfij� <br /> PUMP INSTALLATION: Contractor 0, <br /> Type of Pump 4e` 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 /> « = C3 P f <br /> I hereby agree to comply with all laws and regulations of the an Joaquin Lifeal Health 51-strict <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED � .�'�''-r. TITLE <br /> (DRAW PLOT `P -AN ON REVERSE SIDE) / r� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P I ROUT INSPECTION PHMEj I/ INAL INSPECT IO <br /> INSPECTION BY -/. DATE 1,,117177 INSPECTION BY DATE ,z <br /> 6177 _ 2M <br />_,___ E H 1426 Rev..• /-74- -- - <br />