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t_ 'Ie"' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOi O iCE USE: 11601 E. Hazelton Ave. , Stockton, Calif. <br /> / 10 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27'jS7 kJ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued2 <br /> (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 ie made liance with San Joaquin <br /> County Ordinance No. 1862 and„the Rules and Regulations_ of the 'Joaquin ocal Health District. 4 <br /> JOB ADDRESS/LOCATIONr r C US TRACT <br /> E F <br /> Owner's Name Phone , <br /> Address City . <br /> Contractor'8 Name License # &3Phone � <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 .RECONDITION /-'T DESTRUCTION /-7 <br /> .. PUMP INSTALLATION �-7 PUMP REPAIR'/ ' pump REPLACEMENT /7 <br /> other- 4- <br /> DISTANCE TO NEAREST: . SEPTIC TANK I SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE = PRIVATE DOMESTIC WELL': PUBLIC DOMESTIC WELL' p ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> t <br /> Domestic/private � m - Drilled Dia, of Well Casing - <br /> ,Domestic%public - _ Driv_eaGauge _of .Casngr <br /> Irrigation + = Graver Pack Depth of Grout- Seai ` <br /> Cathodic Protection L_ Rotary Type of Grout. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:'077 7141Z4 <br /> PUMP INSTALLATION: Contractor oL �. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - <br /> Stiate Work Donee <br /> PW REPAIR: /. / State Work Done . . . . <br /> F}E&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 /> AXid �bthe State of California pertaining to or regulating we11'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 /> infdrmation is true to the-best of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR 'TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PRASE i <br /> APPLICATION ACCEPTEDB DATE <br /> ADDITIONAL COMMENTS: `7. <br /> PHASE I RO INSPECT N PHASE IIX//FINAL INSPECTION <br />'INSPECTION BY DATEA 14W-ZZ <br /> INSPECTION BY / Y 1 , 14- DATE r <br /> E H 1426 pwa_ 1-7A' �C,)e h/79 aM <br />