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SAMA 30AQUIN LOCAL .HEALTH DISTRICT <br /> �u ti f <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. ,, Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , <br /> 7.7-1,2.9 4f,b <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I?- <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 Regulatiions,of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S�� �v.CE 4 /�--�f _--- CENSUS TRACT <br /> Owners Named 6A�CW4_ Phone jrr2 7��39 <br /> 11 � � � �� �7r�/"City /✓J D ��� <br /> Address <br /> Contractor's Name License # T- Phone <br /> TYPE OF WORK (Check) : NEW WELL. / ._/ -. DEEP.EN / / RECONDITION / /---DESTRUCTION / <br /> PUMPjI STALLATION 3_ _ PUMP REPAID. / / PUMP kEPLACEMENT /_7 <br /> Other !% / <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, 1' ' Cable "Tool; -Dia. of Well Excavation <br /> Domestic/private # Drilled Dia, of Well Casing <br /> Domestic/public- Driven?---�- -- —Gauge-'6f'"Casing <br /> Irrigation Gravel Pack Depth of Grout Seal H f <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor <br /> Type Uf Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done # - ---- f <br /> DE TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby -.agree to comply with all lawsrdnd_regulations of the San•Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'const'ructi.on. 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 /> information.113 true to th best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G I AND INAL INSPECTION. <br /> SIGNED ° C TITLE <br /> °t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY I 77 � <br /> PHASE I I DATE <br /> APPLICATION ACCEPTED BY 4i <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT .'INSPECTION PHASE III FINAL INSPECTION <br /> I INSPECTION BY DATE INSPECTION-BY DATE Z <br /> 6x.77 _ � <br />