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� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: JW 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -S�t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Vad 22 <br /> (Complete In Triplicate) <br /> 9pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 2nd/or install the work herein described. This application is made in compliance with San Joaqu3 <br /> :ounty Ordinance No. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> fOB ADDRES5/LOCATION CENSUS TRACT - <br /> )wner's Name X, T_� fel f= <br /> ►ddress , •- <br /> City <br /> / <br /> ;ontraetor's Name ,Qoiicenas # Phone Sysr <br /> YPE'OF WORK (Check): NEW WELL ,geDEEPEN •/7 RECONDITION f7 DESTRUCTION,L7 <br /> PUMP INSTALLATION -/� PUMP REPAIR /,_J PUMP REPLACEMENT L7 <br /> Other L-7 <br /> ISTANCE TO NEAREST: SEPTIC TANK • ! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD > CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE MESTIC WELL: PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled - Die-...of-We11 Cabing'�'^"r <br /> Domestic/public ��`-��Driven' •~ � -Gauge-of-Casing= <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> T° ? [' <br /> Disposal Other _ Other Information d <br /> Geophysical Surface Seal Instal ed 'B : <br /> W INSTALLATION: Contractor <br /> Type of Pump <br /> TMP REPLACEMENT: . /7 State Work Done <br /> W 'REPAIR: /7 State Work Done <br /> S TRUCTION OF WELL: Well Diameter Approximate Depth , <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> A the State of California pertaining to or regulating well 'construction. .Within.FIFiEA DAYS <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a ' <br /> LL DRILLERS REPORT of the well and notify them before putting the..well. in.use.... .The above <br /> formation is true to the-best -of my.-knowledge -and belief.' ? I WILL CALL FOR A GROUT INSPECTION <br /> [OR TO GROUTING AND FINAL INSPECTION. ,e�• <br /> GNED . <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE .SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ASE I ope <br /> PLICATION ACCEPTED BYDATE <br /> DITIONAL COM NENTS: 1&14 .7-�-77 <br /> PHASE II DROUT INSPr=ZON I PHASE III FINAL INSPECTION <br /> SPECTION`BY DATE 77 INSPECTION BY DATE <br /> �j�= <br /> E R 1'2A Dner 7—7ICr- <br />