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S.Amt-,404QUIN :=LOCAL t1EALTK*,KST--RTCT K� <br /> FOFxOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Petmit No. 7E-�ao1.�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made ti4o1the 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 /> Coun''ty Ordinance No. 186.2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 52 ° _ Jc-!!�- -- CENSUS TRACT <br /> Owner's Name Phone <br /> k.�C city , <br /> Address = 52 5 � - - <br /> Contractor's Name d- ' �s License # G Gat Phone •S'� 7 , <br /> TYPE OF WORK (Check): NEW WELL :&7' DEEPEN '/-7 RECONDITION %T DESTRUCTION j-7 5 <br /> PUS.' INSTALLATION / / PUMP REPAIR '/ PUMP REPLACEMENT I T <br /> Other'f/ / <br /> t I <br /> DISTANCE TO NEAREST: SEPTIC: TANK [ CL*SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSM FfELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE --`PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> -INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y' <br /> Industrial + Cable Tool Dia. of Well Excavation <br /> _ Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> _..m_ Irrigation Gravel Pack Depth of Grout Seal <br /> tathodic Protection � Rotary Type of Grout <br /> Disposal i Other Other Information <br /> . Geophysical + Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor ~ <br /> 1 Type :of Funip H.P. <br /> i �. <br /> PUMP REPLACEMENT: . /. -/" State Work Done <br /> 1 PUMP REPAIR: / / State'�Work Done ` - <br /> .T . ._ r <br /> DESTRUCTION OF WELL: Well Diameter { Approximate Depth <br /> Describe Material and Pioceduret:-.1 <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,'coinstructi.on-:, Withii vFIFTEEN DAYS <br /> after completion of my work on a new well, I will' furnish the. San.Joaquiu Local Health District a. <br /> J WELL DRILLERS REPORT of the well and notify them before putting the.,-well in,use...: The above l-r <br /> iiiformation .is--true-to:.the-.best .of-my--knowledge and--bel of:-'I 'WZI;L. CA:L '4R A GROUT INSPECTION <br /> 'PRIOR TOG UTING -AND A FINAL INSPECTION. _ . <br /> SIGNED -� TITLE <br /> (DRAW PLOT PLAN ON .REVERSE SIDE ' <br /> F pEPARTMENT USE ONLY <br /> PHASE I _ 11v0?,64fkD DATE <br /> tAPPLICATION ACCEPT BY <br /> � ADDITIONAL COMMENTS:. - <br /> PHASE 11 GROUTeINSPECTION ;" -� � L <br /> IN <br /> . PHASE III A -INSPECTION' <br /> INSPECTION BY _ DATE . INSPECTION BY DATE <br /> e'frr ,f l. CP <br /> 'II I/. a n... -- 7 '7A <br />