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SAN JOAQUIN LOCAL HEALTH. DISTRICT G <br /> FOR OFFICE USE: ry�� 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ?APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9e.`05i!% <br /> v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued %71. 5 <br /> (Complete In Triplicate) r` I' <br /> Application is hereby riade 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 Jos, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distri <br /> JOB ADDRESS/LOCATION „_ 1 CENSUS TRACT <br /> Owner's Name Q ,� -�: � Phone <br /> Address ] k4"f <br /> ���sdrnrn,Y, C//PA � City <br /> Contractor's Name License Phone 5 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN/% RECONDITION /7 DESTRUCTION /7 <br /> E OtherI/SPALLATION / / PUMP REPAIR/� PUMP REPLACEMENT <br /> DISTANCE 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 /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 11 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 t Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: - Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J✓/ State Work Done <br /> State-fa <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''construdtion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TTITLE <br /> Ta QPLAN 'ON REVERSE SIDE) ✓ —7 -"' <br /> PHASE 't <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION;"ACCEPTED BY � y� DATE '�7 C <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPN <br /> INSPECTION BY DATE INSPECTION BY DATEECTI _57? <br /> rn <br />