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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi.OFFICE 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 <br /> f/@ 2 /� /L(�YC-%✓.Q,�_�4-vvsE. (Complete In Triplicate) 2.Z3--y-rio-o6 <br /> Applicationis hereby -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. 1862 and the Rules and gu tions of the San Joaquin Local HeIth District. <br /> U B ADDRESS/LOCATION ENSUS TRACT <br /> Owner's Name Phone , - � <br /> Address City G <br /> Contractor's Name �/d �� WAS .License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_/ / RECONDITION DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / /. PUMP REPLACEMENT <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 <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 By: <br /> 4 <br /> PUMP INSTALLATION: Contractor °YQ <br /> —2wozzl�'_ V—V=2 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done aa,-i <br /> r <br /> PUMP REPAIR: /7 State Work Done <br /> r 35 <br /> DESTRUCTION OF WELL: Well Diameter ` Approximate Depth {�1 <br /> '—� - <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 regulatingiwell '-construction. Within FIFTEEN DAIS <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 C FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AN A FINAL INSP CTION. <br /> SIGNED - TITLE <br /> (DRAW'PLOT PLAN ON- REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ ' <br /> APPLICATION ACCEPTED BY !` jO< DATE J-f-Z-7-7/ <br /> ADDITIONAL COMMENTS: <br /> PHASE lI 9ROUT INSPECTION P S I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1G26 ua„ I_7/, : 1/r77 9M <br />