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SANT JOAQU1N LOCAL HEALTH DISTRICT <br /> D> OFFICE USE. 1601,x. Hazelton Ave. , Stockton, Calyrr <br /> Telephone : (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ Date Issued ----7-./- -;d <br /> (Complete In Triplicate) <br /> )lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> -rd/or install the work herein described. This application is made in compliance with San Joaquin <br /> )unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 3 <br /> ADDRESS/LOCATION l_rnnf (/Z S()f Q _ CENSUS TRACT <br /> --ier I s Name E 7- Tr ck t'n t,,j Phone <br /> Tdr e s s 01396 NN fat l!. 499 C:ity <br /> itractor's Name jkP1]n I#1a-, r '� /1 f�� (�� License Phone <br /> J <br /> 'E OF WORK (Check) : NEW WELL /i / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> —STANCE TO NEAREST: SEPTIC TANK L3QQ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ='I- CESSPOOL/SEEPAGE PIT ,tr/- OTHER ate• <br /> PROPERTY LINE/a- 'PRIVATE DOMESTIC WELL �_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia, of Well Excavation f" <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 _n+n j fe- �\ <br /> _Disposal Other Other Informationj L4 b h.�[ZLt�'n <br /> Geophysical Surface Seal Installed By: _ <br /> '\T INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> T-IP REPLACEMENT: / / State Work Done <br /> "7MP REPAIR: / / State Work Done <br /> ;TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> �1��Gv eLCS �,-r �r��.d e �-l�� ,v c 5 P�� 1��./az i��h�,f l'C�/L /�P,`�l� /�. ;�'-- z>n r-�, �.e•�• _,,1 <br /> Hereby agree to comply with a laws andeg� ulations of the San Joaquin Lo .al Health District <br /> 3 the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> wLL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .MOR TO GROUTING. AND A FINAL INSPECTION. <br /> IGNED TITLE �J—�� <br /> PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY - p <br /> HASE I <br /> PLICATION A dL4PTED .BY DATE <br /> .DITIONAL COMMENTS: f d <br /> PHASE_ II GROUT INSPIQTION PHASE III F N L I PECTION <br /> SPECTION BY -?' DATE , <br /> INSPECTION BY DATE <br />