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V JOAQUIN LOCAL HEALTH DISTRIC- <br /> FOR OFFICE USE: 1602--E. Hazelton Ave. , Stockton, Cal-rt. <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 /> and/or install the work herein described. This application is made in compliance with San Joaqui, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��� 3 f7 �� a .1/ 5 CENSUS TRACT <br /> Owner's Name 1, Phone�W - 5E 7- ]fe <br /> Address .2 /6.2 /6 �� Al-t1/ 91z"61 011 City 2cA/ jL('IcL_r <br /> Contractor's Name AM ecs (,f ea /,, z e,,Ar ep License Phone <br /> TYPE OF WORK (Check) : NEW WELL /7q--DEEPEN /_7 RECONDITION /-7 DESTRUCTION /-j <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK !/on t- 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 DrivenGauge of Casing Z �, .— <br /> _ <br /> �Irrigation Gravel Pack Depth of Grout Seal n (, <br /> Cathodic Protection Rotary Type of Grout 0 <br /> Disposal Other Other Information rn <br /> Geophysical Surface Seal Installed B nr ' v _ <br /> r <br /> PUMP INSTALLATION: Contractor �M CrMc� <br /> Type of Pump 7-14i bri✓-to H.P. , <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 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 GROUTING AND A\ FTWAT. I SPE N. <br /> SIGNED jCa TITLE <br /> ` (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �°, �p q�/ DATE _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r U 1A. 4 - � . . <br />