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• r.1'�-:=.,, ram* <br /> '* SAN JOAQUIN LOCAL. HEALTH DISTRICT U�Pis <br /> E USE: ' 1601 -E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: {209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72:7&z-/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> ti imz F-41TE—M-11 7174. <br /> JOB ADDRESS/LOCATIONS / s`' C�fTS TRACTif CAt <br /> A <br /> Owner's Name Phone r <br /> �- <br /> Address 7City .a14 <br /> a <br /> Contractor's Name License ��, ,� / Phone.' .�2 I <br /> TYPE OF WORK (Check)d: NEW WELL DEEPEN / / RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTAL ATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE 'TO NEAREST: SEPTIC TANK1 �- SEWER LINES PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE- PIT OTHER <br /> PROPERTY LINES PRIVATE DOMESTIC WELL,51.�' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Douoestic/public ,` Driven Gauge of Casing gyp;, ��4wrl- <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 By: _ , _]f___ -, ;,,,✓ <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump H.P. <br /> 3 r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP •.RE•PAIR-: , - a /�/ State Work'-Done' . ! . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T 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 no ify them before putting the..well in use. The above <br /> information is true t thef y owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G AN A FI VP <br /> SIGNED TITLE <br /> "(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE .I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ <br /> i PHASE II GROUT INSPECTION PHASE /FINALfINSPECTION <br />" INSPECTION BY DATE INSPECTION BYIAZ A <br /> ATE Z / <br /> ' ' 4 <br /> U ,,.qa „_-- 1 -7L 1 I _ 2M <br />