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1�.. N JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR-OFFICE USE 160, ". Hazelton Ave. , •Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L--J?0.6 L <br /> t.✓ ,`, THIS PERMIT'EXPIRES l YEAR FROM DATE ISSUED Date Issued ] <br /> (Complete In Triplicate) <br /> Application is :tereby 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 Joaquir <br /> County.Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distk�ct. <br /> JOB ADDRESS/LOCATION o. ,5,� L NSUS TRACT . <br /> Owner's Name' ,4zliaPhone <br /> Address : c <br /> City Lsc.Yl.14O,LV,c <br /> Contractor's Name License i 3 31/Cf Phoil <br /> TYPE OF WORK, (Check) : NEW WELL/ / .DEEPEN '/ / RECONDITION DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other / f <br /> DISTANCE TO. NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 7 . <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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information O <br /> Geophysical Surface Seal Installed Byi <br /> PUMP INSTALLATION; Contractor �/✓�< <br /> Type of Pump Q <br /> PULP 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 t my ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T 0 TI G AN A FIN b I E ; <br /> SIGNED. TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> PHASE <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE LII FIIJAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE{ 7 . <br /> F Dai I_7/. 1777-'_ 2M� <br />