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SAN JOAQUIN LOCAL HtALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 �l5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /5 <br /> J a (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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION g�rf G' / CENSUS TRACT <br /> Owner's Name - - - Phone <br /> Address _ <br /> Contractor's Name �rT-,z% c5L�0S1' a?z ec' j�i�,G(i z,� License e Phone <br /> TYPE..OF WORK (Check) : NEW WELL /�EEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP..REPAIR / / PUMP REPLACEMENT /•-��-� . T ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES 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 able Tool Dia, of Well Excavation <br /> �--D'omestic/private Drilled Dia, of Well Casing w > <br /> Domestic/public Driven Gauge of Casing /® g <br />.r_ Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary ,Type of Grout <br /> Disposal Other -- Other Information x <br /> 4 <br /> Geophysical _ - __Su-rf.ace Seal Ins called By: A-1 <br /> PUMP INSTALLATION: Contractor TJX;.~ <br /> Type of Pump , ,O` Su,! - H.P. <br /> PUMP REPLACEMENT: / tate Work Done _ <br /> PUMP .REPAIR: / / State Work Done Y <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 3 <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i <br /> and the State of California pertaining to or regulating wel.l'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 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 F NAL INS EC <br /> SIGNED TITLE yc� <br /> (DRAW PLOT 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 PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 .4,Sr�j�' � <br /> o,�7 7 _ 2M <br />