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r= <br /> d JOAQUIN LOCAL HEALTH DISTRIC` <br /> (} . <br /> FOFFICE USE: 16O�E. Hazelton Ave. , ;Stockton, Ca�4., <br /> Te.lephone:. (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. 7,7- <br /> THIS <br /> 7 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> A,pplicat"ion 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 Joaqui <br /> Zounty Ordinance No. 1862 and the Rules and Regulation of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION lG CENSUS TRACT <br /> owner's Name L ! ! aL VEt_6PHL&Z _ Phone <br /> Xddress ..... �� _ _va k � � - City ', <br /> contractor's Name 1a 1. �FLL .E 1 � r License 4�r 4 Z Phone 'q - <br /> FYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT—.'/-7 . <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES 100T1 PIT PRIVY <br /> SEWAGE DISPOSAL 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 Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well. Casing �^ r <br /> Domestic/public Driven Gauge of Casing 2 <br /> Irrigationravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information � I <br /> Geophysical Surface Seal Installed By:— <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <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 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 DRILLE,q REPORT of the well and notify them before putting the..well in use. The above i <br /> informatigdAs true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO . UTINGAND FIN INSP CTI <br /> SIGNED ' TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY "'? r' DATE / <br /> i <br /> 'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEM�z <br /> PHASE III/FINAL INSPECTION <br /> INSPECTION BY �P <br /> DATE INSPECTION BY f'/J DATE <br /> _ - r c2M <br />