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SAN JOAQUIN LOCAL .-HEALTH DISTRICT <br /> FOF:;OFFICE USE: 1601 E. Hazelton Ave. , Stockton,.,—Calif. <br /> Telephone: (209) ' 466-6781,'.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE .ISSUED Date, Iasued �6 <br /> (Complete In Triplicate) <br /> Application is 'hereby made `to the Sen '.?oaquin Local Health District for a, pexmit to-,construct <br /> and/or install the Mork herein described-,''This app- Xication .is made _in ;campliance 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 , Phoael-?S 21 <br /> k <br /> Address city _0_.ea <br /> Contractor's Name Opr"- ` License 4 <br /> TYPE OF WORK (Check}: NEW WELL/ EEPEN 'Jam' RECONDITION / J DESTRUCTION /77 j <br /> PUMP INSTALLATION'E/ PUMP REPAIR -/_7 PUMP REPLACEMENT %7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 L.-fable Tool - Dia.'of Well Excavation 0 of <br /> 4-- 'Domestic/private Drilled Dia. .of Well Casin <br /> _-Domestic/public Driven Gauge of Casing- <br /> Irrigation Gravel Pack Depth of Grout Seal 4 <br /> Cathodic Protection Rotary Type of Grout <br /> 177, Disposal Other Other information <br /> ".. . ' 'Geophysical — Surface Seal Installed 'BX <br />,PUMP- INSTALLATION: Contractor 00 <br /> Type of Pump. H.P; , <br /> PUMP REPLACEMENT: . Ll 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 Taws and regulations of the San-Joaquin Local Health 'District <br /> and the State of Callforuia pertaining to or regulating well'construction. Within.FIFTEEN DAYS <br /> after compleiion 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 FORA GROUT. INSPECTION <br /> PRIOR TO GRO I 'ANPI SPECTION. 9 <br /> SIGNED TITLE <br /> DRAW PLOT- P °-ON REVERSE SIDE _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Cr DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY �$'. .. DATE , 7--/6; INSPECTION BY DATE <br /> E g '1426' ' Raw- 1_74 { f�17C 7u i <br />