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e-0,,o/,, o� r F' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF11 OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�: <br /> THIS PERMIT EXPIRES 1 FEAR FROM .DATE ,ISSUED Date Issued <br /> (Complete In Triplicate) 077- 3,?,0— J y <br /> Application is hereby made to tete 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 loj oks u .{' CENSUS 'BRACT <br /> Ftosst -PJ-0V �� Irt/� limit�(' S /C v Cti� 7)wa. �* <br /> Owner's Nance . _ �A „` go o_ Phone <br /> Address /.� .S Ste' d�� D'�! <br /> city . <br /> Contractor's Name; <br /> License # 'Phone - <br /> TYPE OF WORK (Check) : NEW WELL'1_7/_7 DEEPEN /-7 RECONDITION /7- DESTRUCTION /7 <br /> PUMP INSTALLATION / 'UMP REPAIR -/_7PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE IIOMESTIC 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 � <br /> Disposal Other Other"Information , <br /> Geophysical Surface Seal Installed B .. + <br /> PUMP INSTALLATION: Contractor { <br /> Type of Pump H.P. <br /> PUMP /� / - � <br /> State Work Dane �. �L <br /> t .1 <br /> PUMP .REPAIR: /% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all 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 a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify theta before putting the..well. in.use.. . The above <br /> information is true to the best.of owledge a belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL 1-35-UftJONN. <br /> SIGNED TYLE <br /> DRA P V-PLAN ON RE RS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION" ACCEPTED BY A DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 00WyVPECTION PHASE 11I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPEC ION BY DATE <br /> E H 1426 RGY1 7_71. r' '-. s/ V 4 U �'�. /,e n/yr <br />