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SAN OA UIN LOCAL HEALTH DISTRICT <br /> J Q <br /> FO ;'OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z-47,Y_J <br /> 77-2/a Ja <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��,a�77 <br /> s ,P.4,r�� C__j (Complete In Triplicate) <br /> Application-is'-11,66 y 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. 18662 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (�?%� IO!(�l /' . �Q� �, o7�liG' CENSUS TRACT <br /> Owner's Name e !?ZZ Phone <br /> Address Q /rL��1 C!//2 k141 City, <br /> Contractor's Name <br /> IPA1 y License D;2 P3_Phone ;-,2 fr, <br /> TYPE OF WORK (Check) : NEW WELL.-IF DEEPEN '] f RECONDITION /7 DESTRUCTION / <br /> PUMP INST TION Z PUMP REPAIR17PUMP REPLACEMENT j f <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 727 <br /> Domestic/private Drilled Dia. of Well Casing y <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 'By: <br /> PUMP INSTALLATION: Contractor I'/ <br /> Type of Pump �' r� �^ H.P. <br /> PUMP REPLACEMENT: . I I State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> D„E&TRUCTION OF WELL: r 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 /> f 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 /> - --- - ----- - <br /> PRIOR TOG UTING ANP.,A, PINALj IN ECTION.' <br /> SIGNED r TITLE // <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> F APPLICATION ACCEPTED BY DATE Z � 5 <br /> ; .ADDITIONAL COMMENTS: " <br /> PHASE II GROUT INSPECTI .. <br /> ON - � - "-� - PHASE II FINAL'DATPECTION <br /> INSPECTION BY DATE �r ,YNSPECTION BY. <br /> _ DATE <br /> /7 1� 9M <br />