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Ka <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR, OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. � �F <br /> Telephone: (209) 466-6781 ...-® WT 2.7 } <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 0. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED� / Date Issued ,[ <br /> I' (Complete In Triplicate) 7`715 7-7 <br /> Applicaeion is hereby made to the San Joaquin Local Health District for a permit to construc� t <br /> and/or install the work herein described. This application is made in compliance with San Joaquin ; <br /> County Ordinance No. 18b2 and 'the Rules an Regulations of the San Joaquin Local Health District. I <br /> JOB ADDRESS/LOCATION �� d CENSUS TRACT <br /> Owner's Name I Phone <br /> = 1- <br /> c �1� <br /> Address 57' City -- <br /> Contractor's Name License Phone <br /> ���Oro „^ <br /> ,., <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / DESTRUCTION <br /> NT Ij <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEME <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> "i <br /> PROPERTY LINE -- FRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �. <br /> Industrial Cable Tool Dia, of Well Excavation <br /> D,ia..-ofWell�.Casing�.�-� -----�"— �"c <br /> Domestic/Private illed._ �_ <br /> __�___v <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation -�- -""- " " f"� '�.Gravel Pack 'Depth of Grout Seal - <br /> Rotar Type of. Grout <br /> Cathodic Protection � Y¢�-- --� � <br /> Disposal 'Other Other Information <br /> Geophysical , xf, �, Surface Seal Installed B r <br /> PUMP INSTALLATION: Contractor H.P. <br /> f Type,o.f__Pump <br /> �. <br /> Je— <br /> PUMP REPLACEMENT: State Work Donee_ �p <br /> 4:- . <br /> }PUMP REPAIR: / / State Work Done - <br /> IDES,TRUGTION OF WELL: Well Diameter Approximate- Depth <br /> Describe Material and Procedure <br /> r <br /> II 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 is true to the best of my knowledge and belief. I WILL QkLL FOR A GROUT INSPECTION <br /> ,PRIOR TO GROUTING &,ENAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> 4 PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> 'ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION PHAS I I/FI AL INSPECTION <br /> jINSPECTION BY DATE INSPECTION BY DATE <br /> I/I7 <br /> 13 1A9A D— 1_71L <br />