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ti <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB:6FFICE USE: r / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��IJ <br /> i� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> I (Complete In. Triplicate) <br /> Application is hereby made to the San Joaquin Local Hoalth District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <br /> County Ordinance No. 18fi2 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION yT�'S'� �'� PO r� �7 _ CENSUS TRACT <br /> Owner's Name .�Ms. ��% /r'/ /L L r//4'1 <br /> Phone , ��/_ �G 3 k <br /> Address . - u �� /� �fJ� City S' f G r <br /> I <br /> ��� /^ !JlI2, (� License '-? & Phone L7-sS T <br /> .Contractor s Name ✓ �/ /� <br /> TYPE OF WORK (Check): NEW WELL �../�.' r DEEPEN '/ RECONDITION /-7- DESTRUCTION f 7 <br /> PUMP IN /-7PUMP REPAIR /_7 PUMP REPLACEMENT 4 <br /> ' Other �1_7 <br /> 1 A <br />'.' DISTANCE TO NEAREST: SEPTIC TANK ".SEWER LINES PIT PRIVY ' <br /> SEWAGE•DISP05AL FII.D€ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL- ', CONSTRUCTION SPECIFICATIONS v <br />° Industrial i Cable Tool Dia. of Well Excavation <br /> _7- Domestic/private j Drilled 4 Dia. of Well Casing 60t <br /> Domestic/public 1 Driven Gauge of Casing / <br /> Irrigation -a' Gravel Pack, Depth of Grout Seal' TVd <br /> Cathodic ProtectionT Rotary Type of Grout % /3'Mf <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed B i <br /> PUMP INSTALLATION: .-Contractor <br /> Type ;of Pump . A.P. <br /> PUMP REPLACEMENT: / / State Work Done R <br /> PUNPIREPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Wel1, Diameter �'. '� Approximate Depth <br /> Descrl be. Material and Procedure <br /> t <br /> I hereby agree .to comply with all laws and regulationa-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, 1 will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the Drell and notify them before putting-the .well. in.use.... .The above <br /> } information is true to the-Vest .of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG IN AND A FINAL INSPECTION. ` <br /> SIGNED ".: TITLE <br /> DRAWPLOT .PLAN_.ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLYPHASE I <br /> w _ <br /> APPLICATION ACCEPTED BY tea^^ DATE <br /> ADDITIONAL COMMENTS: � • <br /> PHASE 11 GROUT 'INSPECTION PHASE IIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE e� <br />