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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk'OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. frrdll . <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <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 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 1-7Q 6 , 1 x!a[; � _ .��!.... ... .._._,__. CENSUS TRACT <br /> Owner's Name _ � X7_4 Phone 33-Z>?V_11 ^ <br /> Address <br /> (> i` A vee. <br /> City .tiJ - - <br /> Contractor's Name '` License Phone ' <br /> I <br /> TYPE 4F WORK (Check) : NEW-14 <br /> ELL / / DEEPEN '/ / RECONDITION./ / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'PIT PRIVY <br /> SEWAGE IISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY`1,INE -- PRIVATE DOMESTIC WELL _Y i PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ . <br /> Industrial Cable Tool Dia, of Well Excavation V <br /> Domestic/private Drilled Dia, of Well sCasing <br /> 2,Domestic%public ,;�. `Driven� Gauge of Casing <br /> -1 0iIrrigation } ! ii --Gravel `Pack Depth of ,Grou,t Seal' <br /> Cathodic Protection Rotary Type of Gtout <br /> Disposals ;} w;' Qther,)m� Other Information_• <br /> Geophysical rJ Surface Seal Installed By : fit <br /> PUMP INSTALLATION: Contractor r-77 <br /> Type of Pump `H,P. <br /> PUMP REPLACEMENT: / / State Work Done z <br /> PUMP .REPAIR: / / State Work Done I <br /> DESTRUCTION OF WELL: ,. Well Diameter_l, Approximate Depth <br /> tescri8e Material 'and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District s <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 'thewell 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 GRO ING AND A NAL NSPECTION. <br /> SIGNED C&1& TITLE{ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY, <br /> PHASE I <br /> APPLICATION ACCEPTED BY C /��+�- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I1j/FINA1,.e INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> 2M <br />