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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�' GfCC <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /1. 7-7, <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 Joaqu <br /> County Ordinance No. 1862 and 'the Rules and_ Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION �1/DbY✓/i�CPC �C CENSUS TRACT <br /> AAr <br /> Owner's Name � 1�/1 `�,Q �itz� Phone <br /> Address City <br /> Contractor's Name AL/J1 License IFXfJIZTPhone i/�v <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN '/ / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTAL TION/ / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK !Dd SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ; Cable Tool Dia. of Well Excavation //,1/// <br /> Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing i' <br /> Irrigation Gravel Pack Depth of Grout Seal d � <br /> Cathodic Protection pe,, .Rotary Type of, Grout rZ�' <br /> Disposal Other Other Information_ <br /> Geophysical t Surface Seal Installed BY: Mn, <br /> PUMP INSTALLATION: Contractor .222Qn " <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State .Work Done <br /> PUMP .REPAIR: " / / State Work Done- <br /> DESTRUCTION OF WELL: <br /> oneDESTRUCTION0FWELL: Well Diameter ; h 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 <br /> WELL-DRILLERS REPORT-of-the well and notify them before putting the well in use. The above <br /> information is true to the be t o my l wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTI F N IAND N ECT <br /> SIGNED ' TITLE <br /> :,�DM PLIDT PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ � �j <br /> APPLICATION ACCEPTED BY /(%tom /( w / /dao DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 'INSPECTION BY // INSPECTION BY - DATE - Z-3' <br />