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_ SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> r"Ok,OFP16E USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. 4 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 00 3— (S0--07 <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 /> JDB ADDRESS/LOCATION CENSUS. TRACT <br /> Owner's Name ; -Wat Phone <br /> Address A 1243) d. 1ka rn LUL - - - - - --- City ' <br /> Contractor's NameeJ err' u . g- Irk ar' _.License �� Phone <br /> i <br /> TYPE OF WORK (Check) : --NEW WELL/-7 DEEPEN /_/ RECONDITION / / DESTRUCTION /^T <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES PIT PRIVY <br /> SEWAGE-DISPOSAL FIELD - - - CESSPOOL/SEEPAGE PIT -OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC-WELL-r! ! J -PUBLIC DOMESTIC .WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation s <br /> Domestic/private Drilled Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing i1 <br /> Irrigation Gravel Pack -~ Depth of Grout Seal <br /> Cathodic Protection Rotary_ '' r Type of Grout <br /> Disposal Other �- _ - Other Information <br /> Geophysical -- Surface Seal Installed B <br /> r PUMP INSTALLATIDN: Contractor - <br /> Tyrof Pump <br /> Su irn Z hou.) u icy - <br /> PUMP REPLACEMENT: / / State 'Work Done ^_ <br /> PUMP--. - � /d // State 'Work Done <br /> h _ _ <br /> IDES-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 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 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 s ue to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />! PRIOR TO A FINAL INSPECTION. <br /> SIGNED", TITLE r <br /> ;(DRAW PLOT' PLAN .ON REVERSE SID04r <br /> /�dam FOR DEPARTMENT USE ONLY Ilk <br /> ' \ <br /> PHASE I k;}� c DATE e2e <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 1'-' PHASE II/FINAL INSPECT ON <br /> INSPECTION BY DATE �!' ` INSPECTION BY ATE qj `Z <br /> ; 1177 2M <br />