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x J <br /> -SAN JOAQUIN LOCAL 'AEALTH 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 No. gp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r 1 <br /> (Complete In Triplicate) € <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct r <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 �� �Q S� CENSUS TRACT + <br /> Owner's Name I(OPhone <br /> c� l.?�1c 3Lt cit � <br /> Address y�u�1N1 U14-L� <br /> k - - C- <br /> Contractor's Name l F,LL. Lill' J License #. o Phone4Z-i�5 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL. 9DEEPEN-'/_/7 RECONDITION._/_-/ .DESTRUCT.ION_/_T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> ._ Other / / 7 — f <br /> DISTANCE TO NEAREST: SSP.TIC "fiANIC EWER LINES ° IT 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 oQ . <br /> Industrial �,'�, Cable Tool Dia. 'af Well Excavation 7 2 <br />�omestic/private Drilled- : K, i Dia. 'of Well-Casing <br /> omestic/public Driven Gauge of Casing <br /> Irrigation ravel Pack Depth of Grout Seal SO <br /> Cathodic Protection uel-­Rotary,. Type of Grout <br /> Disposal Other Other Information c <br /> Geophysical (Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump fi�. ``� H.P.,, [ . <br /> PUMP REPLACEMENT: J ./ 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 regulatiohis 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 we11°,and notify them before puttingthe.-well in use. The above <br /> information is true to the best of--Ty knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT D A FINAL NSPECT'ION. <br /> SIGNED TITLE <br /> (DRAW,-PLOT PLAN-ON-REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY A4 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II INSVECTION P /FINAL INSP ' <br /> INSPECTION BY DATE , ? / INSPECTION BY DATECTION "i"I <br /> E H 142T %-1177 <br /> Rev. 1-74 ' <br />