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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO 7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .l�/3-aS <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe 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 Heal.thr,District. <br /> �yr � <br /> JOE ADDRESS/-�.OG�ATION � _ CENSUS TRACT r <br /> Owner's Name et <br /> � ��I fi✓ . CLO � Phone <br /> Address a �� 1 �r%i a. City , --- <br /> Contractor's Name 57c . ! - -License-I.,: Phone <br /> _ <br />'"TYPE OF WORK (Check)% NEW WELL ,/ -7 DEEPEN RECONDITION f-7 DESTRUCTION <br /> PUMP INSTALLATION -/ '/, PUMP REPAIR-/_ PUMP REPLACEMENT /? j <br /> Other 1/7 <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 "I Cable Tool Dia. of Well Excavation <br /> ' Domestic/private '1. Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br />[ , Irrigation j Gravel. Pack _ Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type. of Pump <br /> E PUMP REPLACEMENT: /_7 State Work Done , <br /> r PUNF REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> �p floe, Approx mate Depth S 4-1 <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"construttion. 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 th m 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 GR TING AND A FI.NAL INSPECTION. <br /> SIGNED - TITLE n - <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /07// <br /> APPLICATION ACCEPTED BY DATE ' ` <br /> ADDITIONAL COMMENTS: % <br /> - PHASE II GROUT INSPECTION PHASE I FIN INSPE IO <br /> . INSPECTION BY DATE INSPECTION BY DATE L 75 <br /> � <br /> R 4 1A2fi Rav_ 9'-71L r' 22M <br />