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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SFO& OFFICE USE: - 1601 E. Hazelton Ave. , Stockton, Calif. <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 "1 -? , <br /> (Complete In Triplicate) <br /> lipplication 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 /> --1 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> timer's Name L/-'i-t-IV 'T/A!! i /) Phone <br /> Address5 f 33 L- PS-L %/ER R /1) City /f C-1`'}A go e-A4. <br /> ;ontractor's Name /41?2_ Cj �L°�� DR(LLll, License #-4.2 �a Phone <br /> YPE OF WORK (Check) : NEW WELL DEEPEN//7 RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION Y PUMP REPAIR 17 PUMP REPLACEMENT /7 <br /> Other / 7 <br /> ilISTANCE TO NEAREST: SEPTIC TANK j5� % SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER U <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 i 2 " <br /> -_L( Domestic/private Drilled Dia, of Well Casing f{^ <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 Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor --0�� if z(z5"76 f �\ <br /> Type of Pump H.P. a <br /> UMP REPLACEMENT: /% State Work Done <br /> PUMP .REPAIR: State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> _nd 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 /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation 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 /> °IGNED . � r / OD TITLE <br /> {D AW PLOT ON REVERSE <br /> SIDE) <br /> -uHASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> '7/sem <br /> nDDITIONAL COMMENTS: /1AA111 DATE <br /> // <br /> PHASE II GROUT INSPECTION PHASE II Fiat, INSPECTION <br /> NSPECTION BY DATE INSPECTIONBY DATE /o /y <br /> F 11 IATA <br />