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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1501 E. Hazelton Ave. , Stockton, Calif. I <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '216- Y40 <br /> 76- F7P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued as-a -7G <br /> (Complete In Triplicate) <br /> Application is hereby made to the Satz 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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION &71/ 7/� a,/,S ��L 1/ CENSUS TRACT <br /> Owner's Name _ O,[/ ,SL LL �,S ,(��/.. Phoned�� Z/ E <br /> Address / ifr/' S � 1?dfill IV vd - City <br /> Contractor's Name <br /> License (1 S Phonej,/? 2 2 <br /> TYPE OF WORK (Check): NEW WELL/ZT---IIEEPEN '/7 RECONDITION /_-T DESTRUCTIONf7 <br /> 7 <br /> PUMP INSTALLATION /Z/ PUMP REPAIR /� PUMP REPLACEMENT f7 } <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 00 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE4�ZPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE, TYPE OF W <br /> ZLL CONSTRUCTION SPECIFICATIONS cv <br /> Industrial Cable Tool Dia. of Well Excavation 7 \ <br /> domestic/private Drilled Dia. of Well Casing N <br /> Domestic/public Driven Gauge of Casing2177V <br /> Irrigation Gravel Pack Depth of Grout Seal, 6.-0._ �! <br /> Cathodic Protection Rotary Type of Grout S/ +'✓ . <br /> Disposal Other Other Information <br /> . Geophysical Surface Seal. Installed By: <br /> a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /_ State Work Done <br /> } <br /> PES�T'RUCTION 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 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 FOR A GROUT INSPECTION <br /> PRIOR TO GNLTT,4G AND A F;W INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> <ft_��� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1 A0ZV <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/XTNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION INSPECTION BY DATE L-7 <br /> I-74 <br />