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SAN JOAQUIN LOCAL HEALTH DISTRICT 1j <br /> _ FO& OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> y Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> ta, y -7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date: Issued /0 7�'71 <br /> (Complete In Triplicate) j <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct 4 <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. v <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 1 Phone Jai <br /> Address 3 / G/G City _CJ•9�T. i <br /> Contractor's Name Licensees#,�;g <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /� RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION /,_._. PUMP REPAIR/ / PUMP .REPLACEMENT /� <br /> Other.T77'/ �uA f� , L L �-�,�. r� W"C C Ci �W T"yS 4-L <br /> / qel - <br /> DISTANCE TO NEAREST: SEPTIC TANK +' SEWER'LINES PIT PRIVY <br /> /� SEWAGE DISPO�TELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY ,LINE - PRIVATE .DOMESTIC WELL - PUBLIC DOMMESTIC WELL <br /> INTENDED USE . TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> I trial able Tool - -Dia. of-Well Excavation 222 <br /> omestic/private Drilled Dia. of Well Casing ii;'" <br /> Domestic/public Driven Gauge of Casing / �. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> j` 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 /> t afterm -completion of mmy workm-on-am-new well, Im mwill_furnish mthe San Joaquiri`m Local: Health District a <br /> WELL DRILLERS REPORT of the well and notify 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 <br /> PRIOR TO GROUTING D A F . AL INaRECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY /X- <br /> i PHASE IDATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2_2 4-M_/7' <br />