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"IS <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBOFFICE USE: 1601 E-. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209):, 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued -7 j <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 hereiti 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 - .� /''l ®/"cz�GT /� _ _ CENSUS TRACT ' <br /> ��rr <br /> Owner's Name f Phone 7 r/ :.,p <br /> ,.r <br /> AddressCitq �aCi�/�/!�-_ --- <br /> Contractor's Name License #i? & Z Fhone�T'.Z,2 �t <br /> TYPE OF WORK (Check): NEW Wdl,-/? DEEPEN '/ %�RECONDITION 7 DESTRUCTION /_T <br /> r <br /> / / PUMP REPAIR '/-7PUMP REPLACEMENT <br /> PUMP INSTALLATION % r <br /> ' Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER` LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY'.LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL p <br /> - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .,Industrial .. - - - Cable Tool Dia. of Well Excavation U <br /> ^�Domestic/private Drilled Dia. of Well Casing [ ' <br /> Domestic/public Driven Gauge of Casing 1� <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 r <br /> t PUMP INSTALLATION:, Contractor <br /> Type._of .Pump H.P. <br /> PUMP REPLACEMENT: ' / / State Work Done r <br /> PUMP . 1 <br /> REPAIR: / `` State Work Done <br /> R <br /> PES-TRUCTION 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 anew well, ' I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify thein before putting.. the.-well. in.use... .The above <br /> information is true to-the-b'est-of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING �4p A FIN ' INSPECTION. TITLE vKly <br /> SIGNED " <br /> 77 (DRAW PLOT PLAN ON REVERSE SIM4 UA <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I . . , —_S2 <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION <br /> ' INSPECTION BY DATEINSPECTION BY � DATE -l <br /> 2M <br /> 7 u 1A9& t.ne„ I_� if -. <br />