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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOE.OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No4�_7 3, <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date lssue4_/�25 p <br /> ' (Complete In Triplicate) <br /> Application is `hexeby 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 Ru Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� �!`�2�'. ��G .� CENSUS TRACT <br /> Owner's Name !- vcfC [ y, Phone 1� <br /> Address •ff _�J �� /� �.� city J��c�•Cr�-�. <br /> Contractor's Name License Phone 5760 <br /> TYPE OF WORK (Check) : NEW -WELL' DEEPEN/7 ' RECONDITION /—/ DESTRUCTION /_7 I <br /> PUMP INSTALLATION /;e7—PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK9� - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS.0 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 Tooi— Dia. of Well Excavation l' <br /> _, Domestic/private 1 Dril-led-, Dia. of Well Casing w <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gr el''Pack Depth of Grout Seal� �� - •;,� <br /> Cathodic Protection �� Rotary i -' Type of Grout',,. ` <br /> Disposal v t .� Other Other Information <br /> Geophysical *-- ate Surface Seal Installed By: € <br />'F PUMP INSTALLATION: Contractor /C / <br /> Type of Pump ci �.. �.�/ H.P. / <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUMP REPAIR: / / State Work Done <br /> DES-TRUCTION 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 DAY$- <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 t e well and not1fyt,them,before .putting the .well in use. The above <br /> information the best-of, m nowledgeland belief. I WILL CALL FOR A GROUT INSPECTION <br />' PRIOR TO GR4 I D NA_L IN ON. i <br /> 4 SIGNED TITLE - <br /> (DRAW LOT PLAN ON REVERSE SIDE) ° <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ;APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION PHA5E I INAL INSPECT ON n <br /> INSPECTION BY VIP DATE b-? INSPECTION BY DATE -6-1 l . <br /> �- E H 1426•- Rav- 7-7L - <br /> 1/ 7 2M <br />