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S <br /> SAP- -OAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 L4'Hazelton Ave. , Stockton, Califf <br /> ! Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 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 /> snd/or install the work herein described. This application is made in compliance with San Joaqui <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the Sas Joaquin Local Health District. <br /> fOB ADDRESS/LOCATION 2 C /J Cp il'l r, I�r CENSUS TRACT <br /> timer's Name J ck e -' u, cf K r" Phone <br /> sLJ9 3 2 <br /> \ddress ozs/SO /Tc lfr City 4` 7Gh <br /> :ontractor s Name 104 $ Fl • ;,n z 14 T I :�c E. Inn . <br /> License #3� Phone ,� <br /> 'YPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 �J <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> 7✓h �fit/ Other <br /> )ISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal f <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor IJ T S 144 w +- gpTp1'" r <br /> Type of Pump , hi-,r H P 7 �'a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNEDpig ) .� TITLE b a9 •'� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLYPHASE I <br /> APPLICATION ACCEPTED BY /Ff�^ ' � �^ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL SPECTION �/ <br /> INSPECTION BY DATE /L�/� INSPECTION BY TE /-Z 70 <br /> d / v 1/77 . <br />