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E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 9OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit. No.T /S� <br /> �r� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is Ke y 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 p Q 3 7 _ , 1�,/�/ 7 '/20 C S T <br /> Owner's Name Phone Z --� <br /> -77 <br /> t � t <br /> Address 'IF.Z <br /> City <br /> Contractor:s.Name� .sem.,, ,p,q g d- Olicense„ Phone! <br /> a <br /> TYPE OF WORK (Check) : NEW WEL A�r_ D N '/ F/ CONDITION_/L DESTRUChON /_ <br /> PUMP INST TION ' PUMP REPAIR / / J PREPLACEMENT /� <br /> W <br /> 6"Other <br /> DISTANCE TO NEAREST: SEPTIC'TANK SE R-LINES -- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD I 4'CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTICC WELL-- E,UBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL I CONSTkVCT ON SPECIFICATIONS <br /> Industrial Cable Tool Dia. ,Well Excavation <br /> X Domestic/private Drilled �iar-o`f-N �:--Cash <br /> Domestic/public Driven "A,auge of CasinglOr"O <br /> Irrigation Gravel Pack - '*Depth of Grout, Seal <br /> M <br /> Cathodic Protection Rotary Type of Gro <br /> Disposal OtherOther Information <br /> Geophysical Surface Seal Installed By. LF= <br /> PUMP INSTALLATION: Contractor 0 W/✓ �Z. <br /> Type of Pump .S' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> or <br /> DESTRUCTION OF WELL: Well iamet rV'o Approxi;m a Depth 'f� <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 a <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 INAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1004 <br /> APPLICATION ACCEPTED BY Cwt./ DATE ' //—/(S - 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE,IITGROUZ INSPECTION PHASE I:IIJFINAL. INSPECTION <br /> INSPECTION BY DATE //-,?,2- INSPECTION BY ATE —/�� 7 <br /> ��H 1426 Rt, 1-74 S r 1f77 2 <br />