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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> BOVOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-/6 <br /> y THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> j (Complete In Triplicate) <br /> Application is Hereby made tolthe San Joaquin Local Health District for a permit to construct <br /> lianc <br /> with <br /> his <br /> is <br /> in <br /> County Ordinance an Joaquin, <br /> hNo. 1862eand nthe sRules dT <br /> and/or install andRegulationstnof the SaneJoaquinpLocal eHealth SDistrict. <br /> t <br /> � s5'Op p 9 [ p CENSUS TRACT <br /> JOB ADDRESS%LOCATION r.L� <br /> { Phone 1 <br /> Owner's Name <br /> e t City <br /> ` <br /> Address '� - � � <br /> License <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN ./_7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTLATION / / .PUMP REPAIR / / PUMP REPLACEMENT /? <br /> AL <br /> Other './ <br /> 1 , J <br /> DISTANCE TO NEAREST: <br /> SEPTIC -�' SEWER LINES - 0 PIT PRIVY <br /> ,---- --- - --SEWAGETDZSP -FIELD //�rj f"�C OOL/SEEPAGE PIT OTHER r C! <br /> PROPERTY LINE - PRIVAT�E�DOMMESTI.C-WELL_--PUBLIC DOMESTIC WELL <br /> } INTENDED USE_ , --TYPE' 0 . ELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation._ <br /> IDmestrial <br /> —1tt�omestic/private . ... _ Drilled-,� - y Dia. of .Well Casing%_ (9 ` <br /> Domestic/public . Driven ,Gauge-of Casing <br /> -Irrigation i-t4j'` ` - Gravel Pack Depth of Grout Seal <br /> Cathodic Proteetion� Rotary Type of Grout <br /> iOther Information; <br /> Disposal -_.j . %J.f.}t Other <br /> Geophysical _ _ _ Surface Seal Insta-lled B <br /> PUMP INSTALLATION: ContEactor "H•P. <br /> Type of Pump <br /> PUMP REPLACEMENT; / / 'State Work Done <br /> 1 <br /> PUMP .REPAIR: / / State Work Done ' <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 DAT,S <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 /> f. I WILL CALL FOR-AGROUT INSPECTION <br /> information true to the est of my knowledge and belie <br /> ` PRIOR TO GRAYING D A AL SPEC'DION. TTm,v dpi r <br /> SIGNED <br /> r PLANONREVESSIDE <br /> 1 y F DEPARTMENT USE ONLY <br /> 7 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> . ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DAT • .. / SY'?5- <br /> INSPECTION BY DATE INSPECTION BY oto <br /> G 1177 _ ' 2 <br /> n <br /> IS ILIA n.... 1-76 <br />