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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOY, OFFICEUSE: `� 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> G- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. sa 6r ) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x Date Issued <br /> ! ' (Complete In Triplicate) <br /> Application is Aereby 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 k <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. f <br /> � a <br /> JOB ADDRESS/LOCATION 1 TILLL CENSUS TRACT <br /> Owner's Name U '. J Phone <br /> Address C, city <br /> Contractor's Name f c License Phone. <br /> 1 <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL JAI DEEPEN J J RECONDITION DESTRUCTION /7 . . <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT �J�.. �« <br /> Other !:/ J <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES //n -L PITxPRIVY <br /> SEWAGE,'DISPOSAL FIELD CES -L/SE_E�PAGE PIT¢ OTHER <br /> PROPERTY LINE -� PRIVATE DOMESTIC WELL�'� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial rt Cable Tool Dia:`{-of"Well' Excavation <br /> Domestic/private 1 Drilled Dia. of Well' Casing <br /> I Driven Gauge of Casing- <br /> Domestic/public <br /> Irrigation �� Gravel, Pack' j Depth of Grout Seal <br /> ,Cathodic Protection i Rotary" Type of Grout 9 <br /> Disposal Other Other Info'mation <br /> Geophysical- ! Surface Seal Installed By: .. <br /> PUMP INSTALLATION: Contractor x �/tom t H.P. <br /> r ' Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> Q <br /> i _ tate Work Done <br /> 11Q .REPAIR: I I S <br /> � <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter -- <br /> 4 ;esribe Materiali nd Pr edure ' <br /> I hereby agree `to comply with all laWs and regula ions of the San Joaqui Local Health bistrict <br /> land the State of California ,pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion of my work'bn anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of theiwell and notify them before putting the well in use. The above <br /> information is9true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 7—PRIOR TO GROUTING AND A FINAL INSPECTION. TITT��-- -5 & <br /> SIGNED i L . ♦ �(� I1 , <br /> (DRAW PLOT PL ON REVERSE SIDE) <br /> LA- <br /> DEPARTMENT USE ONLY <br /> PHASE I DATE }_ <br /> APPLICATION ACCEPTED BY tip _ <br /> ADDITIONAL COMMENTS: PHAS III�IN L,INSPECTLFIN'PHA II OUT �INSPECTIOINSPECTION BY }DATE ,s r 7 INSPECTION BY <" DATE Q <br /> A 1177 _ 2M <br />