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Il�ycJ . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O <br /> i6D1 E. Hazelton Ave. , Stockton, Calif. <br /> F _OFFICE USE: <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7- -7 <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 workl1herein described. This application is made in compliance with San Joaquin <br /> lations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules and ReguIII 1P <br /> JOB ADDRESS/LOCATION . J Ll)d CENSUS TRACT <br /> Ign <br /> Owner's Name 14 <br /> Phone <br /> y <br /> Address E JQ 0� Cit <br /> C �&2�-S <br /> Contractor's Name l L <br /> e License # 7&f QZ Phone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> "PUMP INST LATION f / PUMP REPAIR / PUMP REPLACEMENT /� <br /> UL4 <br /> I rOther <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PITPRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL w ' CONSTRUCTION SPECIFICATIONS <br /> n.Y Industrial Cable Tool �� Dia. of Well Excavation <br /> -Domestic/private Drilled -Dia.-.of Well Casing <br /> Domestic/Public <br /> Driven Gauge of'Casing 2- <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> • , . <br /> Cathodic ProtectionRotary' Type of Grout <br /> ��� ' Ofher Information -- � <br /> Disposal' �, Other Surface Seal Installed By:.. <br /> Geophysical ;' <br /> PUMP INSTALLATION: Contractor H•P. <br /> Type of Pump <br /> t; PUMP REPLACEMENT:; / / State WorkLDone <br /> PUMP7REPAIR: / / ..State:Work Done x� <br /> DESTRUCTION OF WELL: Well�DiameteY ' „ - ',,,''App`roximate Depth <br /> Describe Material and Procedure y <br /> q t ,y _ 'a. <br /> I hereby agree to comply with all laws and -regulations of the San- Joaquin Local Health District <br /> and the State of Calif'ornia,pertaining to or regulating well'-construction. Within FIFTEEN DAYS <br /> on a new will furnish the San Joaquin -Local Health District <br /> after completion of my work <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,IIA FIN,4L ,INSPECTIOPL <br /> SIGNED tITLE ' <br /> ,I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ,a y OR, D1jieAKf1qhNT USE ONLY <br /> PHASE I DATE 4;)!1 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I� PHASE III/FINAL INSPECTION <br /> PHASE 1'r GROUT INSPECTION J DATE -' <br /> INSPECTION BY ���, DATE INSPECTION BY <br /> �y 77 2M <br /> +. t? T4 1LW; Rao. I'i 74 ' <br />