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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, -Calif. t <br /> - Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zz__& EY9 <br /> THIS ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -ate-1J <br /> (Complete In Triplicate) f <br /> Application is hereby made to;the San Joaquin Local Health District for a permit to construct <br /> and/or install the work here ri1described. This application is made in compliance with San Joaquin, <br /> County Ordinance No. 1862 and'rthe Rules -and Regulations of the San Joaquin Local Health District. 1 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone — 2'// <br /> Address (� c A& <br /> i►. L <br /> City SCA_ <br /> ContractorTs Name ,� No m ' 02 g License # Phone <br /> TYPE OF WORK (Check) : NEW WE7 L / I DEEPEN / /4 "RECONblTION'/T"/ DESTRUCTION /� <br /> -��- — . ..._.�. ... <br /> PUMP INSTALLATION !U{' PUMP REPAIR /% PUMP'REPLACEMENT f� <br /> Other � . <br /> DISTANCE TO NEAREST: SEPTIC' -TANK !._ SEWER LINES _ PIT PRIVY ; <br /> SEWAGE bISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT fs a OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial C Cable Tool Dia. of Well Excavation <br /> Domestic/private q Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing Q <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection f Rotary Type of Grout <br /> Disposal A. Other Other Information <br /> Geophysical .j, . * � Surface Seal Installed By:. <br />- <br /> PUMP INSTALLATION: Contractor jjMj Ve /Z c <br /> Type of Pump - - -� H.P. <br /> PUMP REPLACEMENT: / / State Work Done_,- <br /> PUMP .REPAIR: / / State Work Done _ `{{ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure r = t <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 /> I will furnish the San Joaquin Local Health District a <br /> after completion of my work on a new well, , <br /> WELL DRILLERS REPORT of the sell 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 /> PRIOR TO GROUTINp AND A FIN INSPECTION. 169 <br /> SIGNED I TITLE <br /> t: (DRAW PLOT PLAN ON REVERSE SI <br /> 3 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � . DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE If GROUTINSPECTION PHASE?: TI/FINAL INSPECTION <br /> INSPECTION BY ;DATE INSPECTION BY E <br /> or�77 <br /> cu <br /> 1 I.1)4 n..__ i-7 A - - <br />