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�I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: - 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S=S/81u <br /> F THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .Date Issued Jot 1 <br /> i (Complete In. Triplicate) <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 Joaqui- <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 .1 Q 0 51 6d AIS7 E j2 C Phone <br /> Address z - A G city - S,;��f,6-76741 <br /> Contractor's Name P. � License ' 'GGD,� Phone <br /> TYPE OF WORK (Check;: NEW. WELL/ DEEPEN '/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTLATION / / PUMP REPAIR -/7 PUMP REPLACEMENT <br /> Other / / <br /> I DISTANCE TO NEAREST: SEPTIC TANK (()Q' 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 <br /> Gauge of Casing <br /> Irrigation Gravel Pack- Depth of .Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal V Other. ..__._ _.Other Information <br /> Geophysical. y Surface_fSeal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> _ t <br /> PUMP :REPAIR: / / State Work Done ; <br /> DES;TRUCTION OF WELL: Well Diameter -_ -` _ T ^ w _ Approximate Depth <br /> Describe Material and Procedure <br /> F <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 `cons.truction.. —Within...FIFTEEN .DAYS <br /> af ter, completion of-viy wV rk on anew 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 GR TING AND A FINAL INSPECTION. <br /> SIGNED , TITLE <br /> (�Wi�� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,l <br /> f APPLICATION ACCEPTED BY ti%�sa,1 DAM <br /> y ADDITIONAL COMMENTS <br /> PHA INSPECTION PHASE . INSPECTION <br /> INSPECTION BY ADATE /_ / j INSPECTION BY DATE G <br /> E H 1426 Pv. 1.-71A ; 1,/7K 9M <br />