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F SAN JOAQUIN LOCAL HEALTH DISTRICT , .f <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, f <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7-7-1,X <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /. Z)-/I-- <br /> (Complete <br /> ssued /Z)/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 /> } <br />,TOB ADDRESS/LOCATION �� �� � 1�J /< CENSUS TRACT � <br /> Owner's.Name L -- Phone { <br /> AddressCity <br /> ,EE <br /> 4 h •f r 4 <br /> Contractors s Name License ��Phone -� .,, . <br /> 45. <br /> is <br /> TYPE OF CORK (Check) :. ,.NEW WEI,L- EEPEN /�/m�RECONDITION / / ...DES.TRU.C ; _''1-7 <br /> PUMP INSTALLATION /. / ' P REPAIR / & ,PUMP p FUCEMENT /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> lUl PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> TENDED USE TYPE ,OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria] ! 2Cable Tool Dia. of Well Excavation <br /> omestic/private }:- Drilled Dia, of Well Casing All N11, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface .Seal Installed By: <br /> PUMP INSTALLATION: Contractor l <br /> Type of Pump H.P. 71 <br /> PUMP REPLACEMENT: / / State Work Done t <br /> i <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �` Approximate Depth () <br /> Describe 'Material and Procedure N <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 thein before putting the well in use. The above <br /> information is true'-,t6 the best�f, my knowledge and belief. '•FI WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO R TING D A F AL FIN'SPECTION. <br /> SIGNED-- -.. z. TITLE <br /> r <br /> (DRAW- <br /> PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT-USE ONLY <br /> PHASE I ;'. . �� ) <br /> APPLICATION ACCEPTED BY' s DATE- <br /> ADDITIONAL COMMENTS: f ' ` <br /> PHASE II QROUT INSPECTION PHASE III/FINAL INSPECTION-, <br /> INSPECTION BY DATE ✓ INSPECTION BY ,/ DATE .. <br /> 1177. _ i2M <br /> F. K ll �h 1Do:r i_7G <br />