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3 �AN JOAQUIN LOCAL HEALTH DISTRICT <br /> Stockton Calif. <br /> FOE OFFICE USE: ].601 E. Hazelton Ave. , <br /> U Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete in Triplicate) - <br /> Application is hereby 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. -9 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> o/ J Phone <br /> Address / /V 7-)V"G-7 y / — - City <br /> Contractor's Name® �-4!- Aq 7-u License hone <br /> TYPE OF WORK (check): , NEW WELL DEEPEN /�/� RECONDITION' I-7 DESTRUCTION /'7 - I' <br /> PUMP INSTALLATION PUMP REPAIR I / PUMP REPLACEMENT L7 <br /> Other 1 / Ut `' <br /> DISTANCE TO NEAREST: TANK, LINES <br /> SEPTIC TANPIT PRIVY' <br /> SEWAGE DISPOSAL IELD CESSPOOL IS HEPA.QE PIT OTHER <br /> PROPERTY LIN RIVATE'DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE "TYPE 'OF WELT. r CONSTRUCTION SPECIFICATI S <br /> Industrial n. Cable Tool Dia. of Well. Excavation. <br /> — Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of.Casing d <br /> Irrigation Gravel' Pack Depth of Grout Seal ' <br /> Cathodic Protection ✓ Rotary; Type of Grout <br /> DisposalOther Other Information <br /> r Geophysical Surface Seal Installed B �N� S <br /> ° ,P e <br /> PUMP INSTALLATION: h ContractorL��i- U �� <br /> H.P. <br /> Type of PV <br /> r <br /> PUMP REPLACEMENT: / / aState Work Done <br /> PUMP .REPAIR. State,Work Done <br /> DESTRUCTION -OF WELL: Weil Diametertow. Approximate Depth <br /> Describe Material and Procedure <br /> - y <br /> I ,.hereby agree to comply with all laws and regulations° of the San Joaquin Local Health District <br /> and the State. of,Califoruia pertaining to or regulating well•construction. Within FIPTERN DAYS.y <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 ab6ve <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT I SPECTIEH+1. <br /> PRIOR TO GRPUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W PLAN ON RSE SIDE <br /> DEP MENT USE ONLY <br /> PHASE DATE <br /> APPLICATIONzz <br /> APPLICATION ACCEP B ��A vL� <br /> j ADDITIONAL COMMENTS: ' <br /> � PHASE II GROUT INSPECTION PHASE • Ij1�'INArL INSPECTION' , <br /> INSPECTION ,BY DATE INSPECTION BY, DATE <br /> t IR II'lLm Rau_ 1w74'%,e. }Gd,� �11`r°�''�/���'�!� �7�. .�-'1/yr �. L./�-�✓� 'f` <br />