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SAN JOAQUIN LOCAL, HEALTH DISTRICT I, <br /> FOF:.OFFICE USE: ' 61AI 1601 E. Hazelton Ave. , ,Stockton, Calif._ <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit. No. 17- T77 <br /> 17-9y5 1° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued �7--7 5-,y7 <br /> ' (Complete• In Triplicate) Oct /4/- f/P <br /> Application is '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 Regulations of the San Joaquin Local Health District. <br /> Y VA <br /> JOB ADDRESS/LOCATION %�, 7 ° �j� G'jj( L-y� O,(� li(�, 9�j' � �{/ (�49NSUS TRACT <br /> Owner's Name Phone <br /> City zo�� <br /> Address ���--,_� • YY7!(_�__5 lQ��� Ci <br /> ......,__. f <br /> Contractor's Name License # S Phone /zZ <br /> TYPE OF WORK (Check) : NEW WELL A7 DEEPEN/ / RECONDITION /_7 DESTRUCTION /_7 y� <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <br /> -- — SEWAGE- DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F' 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 /> _�A Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing % '9 <br /> >_ <br /> `-Irrigation' Gravel Pack Depth--of-Grout 'Seal GT. <br /> _'Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> 'Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> LAA <br /> Type of Pump .Q/YJ� �[�'' H.P. : 1E: <br /> PUMP REPLACEMENT: / / State 'Work Done <br /> PUMP `.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' Describe. Material,and. P.rocedure:._.._.. . <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of.- Cali-fornia 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 RRPORT of the well and notify them before putting the well in use. The above . <br /> information is.true to-•-the-1 est-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR 'TO GRO AND A FIN PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> rrr FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 1APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II-GROUT INSPECTT PHASE I;4/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ter. _ -. - �- • ,-. t .. . ._ �._.•.._�/U7f-G��' !Jf✓'��//,�1 / '7• sfM <br />