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,�'a: �/e_.o� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ° <br /> Telephone•. (209) 466-6781 <br /> APPLICATION FOR WELLCONSTRUCTION OR PUMP PERMIT Permit No�rl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) Vo -2/ <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. 1852 and the Rules and Regulations of the Sah Joaquin Local' Health District. <br /> . <br /> JOB ADDRESS/LOCATION IQW . g� A1ENSUS TRACT <br /> Owner's Name /V Y9 -1' Phone <br /> Address: ; 9 .,.... ,,... City /,z0, C^e <br /> Contractor's Name License #/ 3 yj hane 6c� <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN '17 RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR-4-7 PUMP REPLACEMENT f7 <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 �t <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ h Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 5. <br /> Disposal Other Other Information <br /> Geophysical y: Surface Seal Installed By. <br /> �10,&-,PUMP INSTALLATION: Contractor <br /> Type of Pump it. r-: H.P. D <br /> PUMA' REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done <br />,DE&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 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 owledge-nd belief. I WILL CALL FOR A GROUT INSPECTION <br />,PRIOR TO SAgy ING ANDA FINAL INS I N <br />!. SIGNED 1TLE <br /> ooe - RAW PLOT PLAN ON REVtRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT$���2 /'- <br /> ADDITIONAL COMMENTS <br /> PHASE II SPECT ON PHASE III FINAL 'INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 1,76 <br />