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i <br /> ;A.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -FO-F. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLIUTION FOR WELL CONSTRUCTION OR 'UMP PERMIT Permit No.7 <br /> T11IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �-- <br /> c. <br /> (Complete In Triplicate) <br /> Applicntion is ' ereby 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 i�-,`'} /-'.'>l� /• f l CENSUS TRACT <br /> Owner's Name / r /'/��� Phone <br /> Address '�� `i'�- -/. -j /i'i'/�<`- /ACX-?f_ �✓.,� <br /> i <br /> r"V ) 1�Y 1C i/ln-' License <br /> Contractor's Name �, 1 - -Y t�i <• <br /> k- <br /> TYPE OF WORK. (Check) : NEW WELL DEEPEN /-T RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other <br /> _ <br /> CiS'rANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> �{ SEWAGE DISPOSAL F;ELD CESSPOOL/SEEPAGE PIT_ OTHER <br /> ,r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -- PUBLIC: DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> . _ _ <br /> Industrial _ Cable Tool Dia, of Well Excavation <br /> r.; <br /> en Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / -\,n <br /> Irrigation Gravel Pack Depth of Crout Seal, <br /> ' g —`— Grout i, <br /> Cathodic Protection � L Rotary Type of -- <br /> Ri` Disposal Other Other Information <br />".,. Geophysical Surface Seal Installed <br /> x.61 y , ) '>�� I )/l• C . <br /> PUMP INSTALLATION: Contractor H.P. / <br /> A Type of Pump i .��/ ' <br /> § PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter <br /> 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 /> 'u+" and the State of California pert.zining to or regulating well construction. Within FIFTBEN DAY <br /> ,.. <br /> after compl�taun of my work on a new well. I will furnish the San Joaquin Local Health District a <br /> '. WELL DRILLERS RL'PORT of the well and notify them before putting the well in use. The above <br /> 5 iuformatiun is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANT) A FINAL, INSPON'. <br /> SIGNEDANON REVE <br /> �;G�-_f��= TITLE <br /> DRAW PLOT PLRSE SIDE <br /> --- FOR DEPARTMENT USE ONLY Ai <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> 111ASE II CR(,UT INSPEC DATE Z <br /> INSPECTION BY� ^- -)ATE _ INSPECTION BY — n <br /> E TI 1=420 1: <br />