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p,} SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: �1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z.Sd$/0 <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-7J <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 is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations off1 the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I w VA /V ' &V . ref CENSUS TRACT <br /> Owner's Name S�/ f" f� CnPhone 9 ,701 <br /> Address es city <br /> Contractor's Name ,� Q �,�_ License # 1WO Phone '13-" -fid <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN_ 3ECOND.IT.IAN..../_.�..DE.S_'I.R.T3C.TLO�L f� <br /> PUMP INSTALLATION/ / PUMP REPAIR PDME REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE �PITt OTHER <br /> PRORERTY LINE_7--PRIVATE DOMESTIC,WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 'SPECIFICATIONS <br /> Industrial T061 Dia. of Well Excavation ' <br /> Domestic/private �. �. , - Drilled :Dia. -of Well Casing <br /> Domestic/public 'Driven' f; ' Gauge ,of Casing w' <br /> Irrigation----­� R ' ,Gravdl- PAck �'' Depth of Grout Se-al ' <br /> Cathodic Protection '.;Rotary Type of Grout - <br /> Disposal Other Other Information i <br /> Geophysical € Surface Seal Installed By: <br /> PUMP INSTALLATION: + Contractor y <br /> FType of Pump H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: A? State Work Done �Z2 ` f . �2! <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth i <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 CAL - FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D A F AL INSPECTION. <br /> SIGNED TITLE <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 G N ECTION PHA II FINAL I SPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE , <br /> F. H 1L26 26 1'2 a 17 1_7 G "` 1/77 2M <br />