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_ SAN JOAQUfN LOCALHEALTH DISTRICT <br /> FOFi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Ca.11f. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 01i PUt41' PERMIT Permit No. (/ <br /> THIS PER11IT EXI'IRES 1 YEAR FROM DATE ISSI'ED Date Issued <br /> (CLmplete In friplicate) <br /> Application is hereby made to th-_ 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 SSaan/ -loaquin Local Health District. <br /> JOB ADDRESS/LOCATIONL1LIl5_C'���-C —._ CENSUS TRACT <br /> _eAdOwner's Name T ,(C�herwy) 1�, ene _$9_z3 _- <br /> Address �?1 ADI /[C/. �_____ City <br /> Contractor's Name L1LGr [�, �. License (t nyrj Phone J <br /> TYPE OF WORK (1:heck) NEW WELL /L/ DEEPEN / / RECONDITION /_/ DESTRUCTION /__7 �} <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REP LACEMENT /-7 k <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK � ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRTVr1'CF TK)tih5'I'IC IJ F,1,E. _-- PUBLIC T)OMESTIC WELL --- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavatijn <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 7 <br /> it <br /> Irrigation :17 <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout — y <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed/ By: <br /> PUMP INSTALLATION: Contractor �G.r�•,� <br /> Type of Pump Tan (r c H.P. 7-o <br /> _ 6 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done } <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> Describe Material and Procedure <br /> — 1 <br /> a � ' <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District f <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 GRO TING AND INSPECTION. <br /> SIGNED �4 TITLE �L�/ — <br /> ( lJ LO LAN ON VERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY ��Zz - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION/ PHASE II /FIN INSPECTION <br /> ION B <br /> INSPECTION BY DATE .�/ INSPECTYG, . � DATE7_�/ ��_ <br /> 0!77 2M <br /> E 11 1426 Rev • 1-74 <br />