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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> i.Ok.OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S- <br /> ' (Complete In Triplicate) <br /> Application is Aereby 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 /> i <br /> JOB ADDRESS/LOCATION , . CENSUCT <br /> bW14ed0h&S <br /> Owner's Name66 <br /> - <br />,Address �-A,0 fJ, City . r <br /> i <br /> Contractor .s Name _fTj1jc, License ; Q / Phone t <br /> s .. .. ,,. <br /> TYPE OF WORK.(.Check) NEW WELL DEEPEN /-J- RECONDITION_`/ 7 DESTRUCTION_/ ,. ... <br /> . .f�"` PUMP"INSTALLATION / / PUMP REPAIR / /PUMP REPLACEMENT /77 <br /> y Other / <br /> DISTANCE 10 NEAREST: SEPTIC TANK d SEWER LINES PIT PRIVY i <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT' OTHER, - ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC.DOMESTIC WELL <br /> INTEN09D USE TYPE OF WELL CONSTRUCTIOW SPECIFICATIONS <br /> ,;Indust#al Cable Tool Dia. of Well Excavation �r ' <br /> I Domestic/private- _ Drilled Dia. of{Well Casing._ <br /> Domestic/pub]is Driven Gauge -of Casing 3Ma_ <br /> Irrigation Gravel Pack Depth of Grout Seal -- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ Sf �f l fd1nP <br /> I zGeophysical " <br /> Surface Seal Installed B � <br /> PUMP .INSTALLATION: Contractor <br /> F Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' � <br /> {�} Describe Material and Procedure <br /> ell <br /> I hereby 'agree to comply with all laws and .regulations of the San Joaquin Local health' istrict . <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,,wil1 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 is true to the best. of, my knowledge and belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED: /Jf. TITLE - $;77 <br /> ► . J I (DRAW PLO F ON REVERSE SIDE) <br /> ¢ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APP,LICATI4N ACCEPTED BY DATE.: p.5-G,3: <br /> ADDITIONAL- COMMENTS <br /> -- ,PHASE PHASE II GROUT INSPECTION ` `� PHASE- III/FINAL IX$PECTIO "°""'`'"P""� <br />€ INSPECTION BY DATE INSPECTION BY DATE <br /> 1177 2M <br />