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x <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: -1601 E. Hazelton'Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> 2 <br /> APPLICATION FOR. WELL CONSTRUCTION OR PUMP PERMIT Permit No. '1�'IS� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> {jf - (Complete In Triplicate) <br /> Application is hereby made`:to the San Joaquin Local Health District for a permit- to construct <br /> 7 and/or install the work herein described. This application is made in compliance-with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin.Local Health District. <br /> JOB ADDRESS/LOCATION J CENSUS TRACT ' <br /> Owner's Name Phone L/71- 1&0 <br /> Address City <br /> s <br /> Contractor's Name _ 4�1_ .-� -rSa-Y:0 License #3 wo7ZV Phone_3_�,_?– 3� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMPfINSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> y 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 . Cable Tool Dia. of Well Excavation f <br /> x. Domesfic/private 1 - -Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing L� e <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 j i A� H.P. <br /> . <br /> PUW REPLACEMENT: / / State Work Done <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 Californialpertaining 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. 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 GR UTING ANJD A FINAL IZiSPECTION. <br /> y SIGNED _� t TITLE _b ^ <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION 'ACCEPTED--BY. . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IW/FINAL INSPECT ON <br /> INSPECTION by DATE INSPECTION-BY-;�; DAT_E <br /> F u IL9h I)— _1­7A - .R` i3177 2M <br />