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F_. <br /> SAN JOAQUIN iOCAL HEALTH DISTRICT <br /> FOS;OFFICE. USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-5 7/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued /a- - 1 <br /> (Complete In Triplicate) <br /> Application is hereby made t.6 the Sian Joaquin Local; Health District for a permit to construct <br /> application is made in compliance uin <br /> and/or install the work herein described. This :app liance with San Joaq <br /> p <br /> County Ordinance No. 1862 andithe Rules and Re8 atone of the Sacs Joaquin Local Health District. ; <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> a <br /> Owner's NameEEjj&dA11A_1_kPhone ' <br /> Address City ,-,- <br /> I <br /> Contractor's Name License #a2 77 Phone 1 <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT 1 ; <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC. TANK SEWER LINF/,S PIT PRIVY <br /> SEWAGE, DISPO ZTELD 4Q CES POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVA MESTIC WELL' PUBLIC DOMESTIC WELL \, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC T 0 S („V <br />'k Industrial A le Tool Dia. of Well Excavation <br /> �omestic/private I Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> rigati.oai i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> nq <br /> Disposal. w I Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done r <br /> PUMP ,REPAIR: / State Work Done <br /> � DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 /> 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. 3n.use... The above <br /> i information is true to the-b t.of my knowledge and belief., I WILL CALI, FOR A 'GROUT INSPECTION <br /> PRIOR TO GROMI19G AND A VILN IN.ZPECXION. <br /> SIGNED . TITLE , r <br /> / (DR#W PLOT PIAN;^ON .REVERSE SIDE <br /> FOR DEPARTMENT <br /> PHASE I <br /> , APPLICATION ACCEPTED BY _ : - DATE /' <br /> , ADDITIONAL COMMENTS: <br /> PHASE 14 GROUT INSPECTION <br /> :�, PHASE III FIN INSPECTION <br /> ti f �� �` - ..,, .. . <br /> ` INSPECTION BY DATE 1 �..INSPECT,IOWAY: DATE /(, <br />