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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0-570FFICE USE: 1601 E. Hazelton Ave. ,- Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 9fp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued (-/r <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 d Ae Z- d N CENSUS TRACT <br /> Owner's Name Phone ' <br /> Address . j d� City <br /> Contractor's NameLicense. # Phone <br /> 17 <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN -/ RECONDITION / f DESTRUCTION /_7 <br /> PUMP /INSTALLATION ;.cc <br /> , PUMP �. REPAIR / PUMP REPLACEMENT %T; �F <br /> Other <br /> DISTANCE TO NEAREST:.A,SEPTIC TANKt,'-L, -; SEWER LINES PIT PRIVY <br /> _SEWAGE DISPOSAL FIELD`; NCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIgi- -- PRIVATE DOMESTfC'4E—LL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE-OF-WELL - _ "_ CONSTRUCTION SPECIFICATIONS v}f <br /> Industrial Cable Tool •., ,,.Dia. of Well Excavation <br /> Domestic/private ! Drilled Dia. 'of Well Casing t <br /> Domestic/public i Driven Gauge!of Casing <br /> Irrigation R Gravel Pack Depth` of Grout#.Seal t - '" Y' vlAl, Q� <br /> Cathodic Protection I . Rotary J ` � Type hof Grout"! '%` t _ q <br /> Disposal ➢ Other Other Information : 0 <br /> Geophysical Surface- Seal-Installed B : <br /> PUMP INSTALLATIONoContractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: . / / State Work Done - <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 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 gMTINZ AND F N PECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE - - <br /> FOR DEPARTMENT USE ONLYPHASE I <br /> f <br /> APPLICATION ACCEPTED BY DATE % 76 <br /> ADDITIONAL CON MEN TS: 7 . <br /> PHASE II GROUT- INSPECTION PHASE FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 7� 6 <br /> -74 2W kJ- <br /> "'"Ti'�Ii• 11.91 n___ �i i <br />