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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na.2 7/v5 _2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 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 Re Mations of the San Joaquin Local Health District. k <br /> 4 <br /> JOB ADDRESS/LOCATION lf?_01t Ne .a CENSUS TRACT T <br /> Owner's Name Aar a A 81g Phone <br /> Address`_ _A _C 1 1 ✓ City FIs <br /> Contractor's Name /.• /J p� License # /('hone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL 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 /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary . Type of Grout �1 <br /> Disposal Other ; , Other Information <br /> Geophysical Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor } <br /> Type of 'Pump "" H.P. <br /> PUMP REPLACEMENT: tState Work Done All c 3&�z §�7 <br /> PUMP .REPAIR: /�V State Work Done <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> • y <br /> I hereby agree to comply with alb. 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 anew 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 CALL FOR A GROUT INSPECTION ? <br /> PRIOR TO GROU73G AND FIN I-NSPVCTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />} APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I M IN PECT V PIAS I/FIN4L INSPECTION <br /> INSPECTION BY DATE / INSPECTION BY DATE 3 7 <br /> 2M <br />