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SAN JOAQUIN LOCAL HEALTH: DISTRICT <br /> FW;*OFFICE USE: �- 11601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �,ry <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <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 appXication is made in compliance with San Joaquin. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `Y /` /7 — CENS' US TRACT <br /> Owner's Name L C /�.i Phone !4/_7 <br /> Address <br /> �� �� City <br /> Contractor's Name �J(, C l License Phonei <br /> TYPE OF WORK'-(Check): NEW WELL / DEEPEN ,/7 RECONDITION /-7' DESTRUCTION %j <br /> PUMP INST LLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE NES =--! PIT PRIVY <br /> SEWAGE DISPOSAL IELDCESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY LINEPRIVATE STIC WELLPUBLIC DOMESTIC WELL �i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> :,Z <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ', <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal I <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: Gr/ <br /> PUMP INSTALLATIONo ' <br /> Contractor (e_,41.0 <br /> Type .of Pump 4 ,T4C oz:z; H.P. <br /> PUMP REPLACEMENT: / / 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 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 Distri'c't 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.,m,-y knowledge and belief. I WILL CALL 'FOR A GROUT INSP,EC I <br /> PRIOR TO GROUTING D A f INAL INS CTION. <br /> SIGNED Y-40—C-11 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDF47- <br /> JIF <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' O I/-7-A <br /> ADDITIONAL COMMENTS: AV o <br /> PHASE II : ROUT INSPEWIOF fPHASE rI14EINAL INSPECTION <br /> INSPECTION BY DAT NSPECTION BY DATE / 7 7 <br /> R H 147 f, I',/7t 9)U <br />