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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone-. (209) 456--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued // �7-717 <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. 186_Z-.and the Rules and Regulations of the Saar Joaquin Local Health District. <br /> .SOB ADDRESS/LOCATION / F �(�' [1 SuS TRACT <br /> Owner's Name4�2phone & [ <br /> Address . City <br /> 44gs'7 <br /> Contractor's Name , fes / LicensET-19900M Phonq <br /> TYPE OF WORK (Check): NEW WELL /t- DEEPEN /-I RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION j_/ PUMP REPAIR /% P1E P REPLACEIENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEXIER LINES PIT ]PRIVY �. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PFT 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 /> A"Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public Driven Gauge of Casing C� <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection i� otary Type of Grout _ 2 S { <br /> Disposal Other Other Information <br /> Geophysical r., Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor z7 �./ <br /> Type of Pump <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 /> I hereby agree to comply with all laws and regulations of the Saga, Joaquin Local. Health District <br /> and the State of California ,pertaining, to or regulating well constructi.on.- Within FIFTEEN DAY'S <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 thewell 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 TP GROUTI MD A FINAL INSPE CP - <br /> SIGNEDA4k <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J <br /> AZ7 . <br /> ,ADDITIONAL COMMENTS; <br /> PHASE ji OUT INSP CTIObT PHAS I/ NAI, INSPECTION <br /> INSPECTION BY DATE /6f/j//7/ INSPECTION BY DATEaa:zz <br /> - <br /> E H Rev. - I-74 1426 5/7.7 <br />