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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-61$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L77 4J <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED DatejIssued 7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permitil:to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1662 and the Rules and Regulations of the San Joaquin Local!iHealth District. <br /> JOB ADDRESS/L TION CENSUS TRACT <br /> C_ _ <br /> Owner's Name Phone 'cv,4Jr1 <br /> k. <br /> Address ( `' ` city . 1 .� <br /> Contractor's Nasse License # Phone <br /> i a . <br /> TYPE OF WORK (Check): NEW WELL '/57 DEEPEN '/_7 RECONDITION / f <br /> _7 DESTRUCTION' / <br /> PUMP INST LATION / / PUMP REPAIR -/-7—pump REPLACEMENT iIl-7 <br /> Other /% ��-- <br /> i <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY i <br /> _• SWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT.-_ _ OTHER <br /> A PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTICiWELL <br /> INTENDED i USE , TYPE-OF :WELL�_ CONSTRUCTION SPECIFICATIONS <br /> _;ndustrial Cable Tool 1 Dia. of Well Excavation 12- <br /> Domestic/private" ysrilled ' Dia. of Well Casing,, <br /> Domestic/.public Driven + Gauge-of'-Casing <br /> /7r- <br /> Irrigation <br /> Irri { <br /> $ Gravel Pack Depth_of Grout- Seal. <br /> Cathodic Protection Mary " Type of Grout <br /> Disposal - 7—.------- --Other Y Other Information ' ' <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump . r� H.P. <br /> PUMP REPLACEMENT: / / State Work Done - ' <br /> PUMP.REPAIR: / State Work-Don <br /> DESTRUCTION OF WELL:', Well Diameter,. . Approximate Depth <br /> Describe,Material and Procedure " <br /> ' - <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 'coristruction. 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..we11 in.use...:! The above <br /> information ig true to the,bes�t.of: my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND INAL INSPECTION. <br /> SIGNED TITLE <br /> ' f DRAW OT PLAN ON REVERSE SIDE <br /> ,.t.. ;...�.,,_.• ._ _n.. FOR_ DEPARTMENT USE.ONLY <br /> PHASE I A �7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASEGRO INSPEION PHA. E I FINAL SPSCTION <br /> INSPECTION B T DATE/C0 CT - V7_4 INSPECTION BY E� <br /> AT <br /> / � -�� <br />