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y 1P)v SAN JOAQUIN LOCAL HEALTH DISTRICT --- <br /> FOfSMFICE USE: 1601 E. Hazelton -Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR, PUMP PERMIT Permit No. ?'S LLd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IL-Zr- <br /> .Z <br /> K (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/orfinstall the work herein described. This application is made In compliance with San Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i JOB ADDRESS/LOCATION Y ' CENSUS TRACT <br /> { <br /> Owner`r � <br /> t <br /> s Name d Phone <br /> Address S` -p-- City <br /> Contractor's Name �icense bane / 7V <br /> TYPE OF WORK (Check) : NEW WELL /Z7 DEEPEN /__ RECONDITION j_� DESTRUCTION %7 <br /> PUMP INSTALLATION 1z4--FUMP-REPAIR j / PUMP REPLACEMENT 1-7 <br /> Other / / ` <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK �-�e-4EWER 4INESS _ - IT PRIVY <br /> SEWAGE DISPOSAL FIELDE5SPOOL/SEEPAGE PIT . OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELLZLa PUBLIC DOMESTIC WELL <br /> ' INTENDED USE -aA TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Ix�c3ustrial ., + Cable Tool Dia. of Well Excavation <br /> G/Domestic/private Drilled . Dia. of Well Casing <br /> 'Domestic/public',,- �,r� , Driven � +Gauge of Casing <br /> Irrigat�an I t � G-> gavel Pack Depth of Grout Sea <br /> i :Cathodic_Protection otary t-Type of Grout E <br /> Disposal `�, '' `�Other ` Other Information <br /> f .Geophydio'al-, ',;Surface Seal Installed $ <br /> PUMP INSTALLATION: Contractor <br /> - _ <br /> Type of PumpH.P. <br /> Ali <br /> PUMP'REPLACEMENT State Work Done <br /> ate, <br /> PUMP 'REPAIR: .�,� i' /� State-Work-Done <br /> E5'TRUCTION OF WELL:-:p.-Well Diameter - �r � Approximate Depth <br /> Describe MA.iafial an Pro re , <br /> I hereby agre�Io comp y w h ally aws-and regsxlations a the San J aquin Local Health District <br /> and the State of California pertai d'6g 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 /> in mation is,tfue•. to k the st of my knowledge ar de belief. I WILL CALL FOR A GROUT INSPECTION <br /> k PRIO GROUTING AN ' SPECTION. iy � <br /> SIGNED , ' E I TITLE c SCJ <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> ^FOR DEPARTMENT USE ONLY <br /> PHASE I �• <br /> APPLICATION ACCEPTED BY DATE/�rzk <br /> : <br /> ADDITIONAL COMMENTS. Q <br /> P I RUT INSPECTIO "-PHASE III FI INSPECTION 1 <br /> INSPECTION BY DATE / INSPECTION BY DATE �` <br /> �1(� Rev. 1-7v4 2M r <br /> �E-�t142',b--� ,,.Ir7!a � - -. <br />