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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOk.'OFFICE USE: ' / 1601 E. Hazelton Ave. , ,Stockton, Calif. F <br /> Telephone: (209) 466-6781Permit No. 7�W/ P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT , <br /> THIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issued _7-.2,1L-27 <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. <br /> JOB ADDRESS/LOCATION �j'l CENSUS TRACE <br /> (� <br /> Owner's Name I ) Phone ' 0 <br /> Address V Citys /� <br /> f&vContractor's Name �G/ License # $hoar ' ✓D <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN/ / RECONDITION /_—T DESTRUCTION <br /> PUMP,INSTALLATION /� PUMP REPAIR /-_W PUMP REPLACEMENT <br /> Other <br /> i <br /> DISTANCE TO NEAREST': SEPTIC TANKSEWER EINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT _ OTHEA �r <br /> PROPERTY LINE PRIVATE DOMESTIC WELI, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT. ONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ;Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Di.sposa'1 Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor —H. <br /> Type. of Pump P. o <br /> PUMP REPLACEMENT: F-1 State Work Done <br /> PUMP .REFAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> I hereby agree to comply with all. laws and regulations of the San .7oaquin Local Hea1Ch (strict . <br /> and the State of California pertaining to or regulating we11''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District 8 <br /> WELL DRILLERS REPORT of the well and notify them before putting the-well in use. The above <br /> I information is true to the best of- my knowledge and belief. I WILL L FOR A GROUT INSPECTION <br /> PRIOR TO GR TING ,AND A FINAL INSPECTION. <br /> SIGNED TITLE . <br /> DRAW HOT PLAN ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE =2L=7'` , <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT. INSPECTION v PHASE III „FINAL INSPECTY0N <br /> f INSPECTION BY DATE INSPECTION BY DATE f <br />