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_ C Y `1 JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 160YE. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7L_1aQ1p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , <br /> (Complete In Triplicate) <br /> )plication 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 /> adB ADDRESS/LOCATION �,!/�,!/ �c �[� �7aj� ; /�f �„ - Jj /f /) :� ., CENSUS TRACT <br /> 1 mer's Name \ _ Phone 36- -,Q 7rJ� <br /> Address Z 7 13 Z City <br /> x <br /> c_ntractor's Name t f%'��� License ?14 Z, 23 Phone .3Gr- _,j;(' <br /> PE OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ J PUMP REPLACEMENT <br /> Other /_/ <br /> I+.STANCE 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 A <br /> _ — Domestic/private Drilled Dia, of Well Casing C <br /> Domestic/public Driven Gauge of Casing < <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> _Disposal Other Other Information <br /> Geophysical (� d Surface Seal Installed By: <br /> P Q INSTALLATION: Contractor Z'a'e c <br /> Type of !Pump H.P. / <br /> P"NT REPLACEMENT: / tate Work Done -+ " , ea <br /> PMT .REPAIR: _ /_ // Sta�e Work Done <br /> it 'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ` Describe Material and Procedure <br /> I iereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> a;_J 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 /> a"'.L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ij 'ormation isAFue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 11tr R TO GROUN p A F N INSPECTIO . <br /> 3TC <br /> MED _� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ?RASE I <br /> iJ 'LICATION ACCEPTED BY DATE /D 7 <br /> U.iITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION v PHASE III/FINAL INSPECTION <br /> 11 PECTION BY DATE —�-- INSPECTION BY DATE <br />