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s A SANyJOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.:OFFICE USE: 3601 E. Hazelton Ave. , Stockton, Calif. <br /> `1. 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 /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct a <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name L Phone $3 l O i <br /> Address 5 Z' No -7 City" dE� CAI.Dr/ <br /> Contractor's Name IL W LL_ CD-/" LJJI,P. ,eV. License # �?S -Phone 75` <br /> TYPE OF WORK (Check): NEW WELL &7 DEEPEN J_7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION & PUMP REPAIR/� PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,_PIT PRIVY p <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER1 � <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL 4i2L A PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casingi' �T , <br /> Domestic/public Driven Gauge of Casing <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 /> PUMP INSTALLATION., Contractor W L3 - L,; G'c1 <br /> Type of Pump H.P. -5-0 <br /> ,jog <br /> PUMP REPLACEMENT: ._ /_7 State Work Done <br /> .PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION 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..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. { <br /> SIGNED TITLE SA LQ5 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS TNSPECT ON <br />;`1:NSPECTIQN BY DATE INSPECTION BY DATE <br /> F�. r <br /> 714//n-- �'/ Pw <br /> R 1; 14 01 A 7b.... rt_7 i r' 1.hnf OM <br />