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WV R L, X 0 7 Fk-N" <br /> �. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. /y <br /> Telephone: (209) 466--6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -.30_)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 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 E CENSUS TRACT <br /> Owner's Name ti ��Z Phone O e <br /> � <br /> Address meg ! Q �e _ ► �_ � City E- sr <br /> Contractor's Name ='tz - q License #33-76,57Phone P2 �.53 <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION ,X PUMP REPAIR / / PUMP REPLACEMENT / � l <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 0PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing (t_ <br /> Irrigation ^ Gravel Pack Depth of Grout Seal I— µ <br /> Cathodic Protection Rotary Type of Grout Ak/U <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumper 1E H.P. <br /> PUMP REPLACEMENT: / / State Work Done r <br /> PUMP .REPAIR: / / State Work Done ` <br /> S <br /> DESTRUCTION OF WELL: Well Diameter 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 /> 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. noti,fy 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 s' <br /> PRIOR TO GROUTING AND FINAL INSPECTION. ^�-� � <br /> SIGNED TITLE �__� <br /> --- - - --- (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION P PliAM IIIIFAINAI INSPEC 0 <br /> INSPENTION BY DATE !NSPECTIIOONBY DATE 'J <br />