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M ►4 R. Fi,+ ,rC.L-r�.­sy <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT p <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave, , Stockton, Calif. I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedli " <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 666 (j(I % `l O1r 2©-, /C;T>'' <br /> � � e I CENSUS TRACT <br /> Owner's Name 1.l A R F/1/Ce- ` e Phone �q�3 y <br /> Address �j r <br /> City <br /> Contractor's Name icense # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP TNSTALLATION�I PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY cx� '• <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ELLINPROPERTY LINE -- PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL- <br /> INTENDED <br /> TENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 <br /> Cathodic Protection Rotary Type of Grout s <br /> -Disposal Other Other Information <br /> Geophysical Surface Seal Installed_ By:______,_ ' <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H,P, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diamete,06/,-) Approximate Depth <br /> -- — <br /> Describe Material and Procedure I <br /> s <br /> I hereby agree to comply with all laws and regillations 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 TOqPj9UT1N9 AND A FINAL. INSPECTION. _ e h& j <br /> SIGNED TITLE w <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DA <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE IT /F NAL INSPECTION <br /> INSPECTION BY DATE Wd INSPECTION BY TE ` <br /> 6J77 9M f <br />