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: AN JOAQUIN LOCAL HEALTH DISTR� <br /> FOF OFFICE USE: l6b'1 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 <br /> (Complete In Triplicate) <br /> Application 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� �n �� �� 17-cNf��� � CENSUS TRACT <br /> Owner's Name e'Ce /z Phone <br /> U/ <br /> , TTD7n.c4 <br /> Address ?,zoe) -7f City `Yllcii .o <br /> Contractor's Name A , �, �ie� idetltl License l�;A_ %Phone '- <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /-T DESTRUCTION /_] <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT A-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1�1_V_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /�.S� 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 r <br /> Domestic/private Drilled Dia. of Well Casing i <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S n f <br /> Cathodic Protection _� Rotary Type of Grout _fie-Y - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: A <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump a H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> Fe <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> -�- Approximate Depth 7e/ <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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A FTNAT IN ECT <br /> SIGNED TITLE 11 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR,DEPARTMFNT USE ONLY <br />— APPLICATION ACCEPTED BY; 16 DATE a 0 <br /> ADDITIONAL COMMENTS / - ,•�(C ic C/-. :.;o. �a %,/. ,c <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE �79 INSPECTION BY DATE <br /> E H 1426 RA,,_ 1_7A 1 /77 ?]AW <br />