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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE:, 160: Hazelton Ave. , Stockton, Cal <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 �a6_7� <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION [- i.SL% AL /, . �L^!Y !�� CENSUS TRACT <br /> Owner's Name ���> �f���� i, c Phone <br /> Address / City <br /> Contractor's Name /��yE , f��6 f f ��, ����u ,�,��, License Phonek�5'�-S%SZ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /_/ DESTRUCTION /-7 <br /> ALL <br /> PUMP INSTATION "IC _ <br /> -'` ' PUMP REPAIR / / PUMP REPLACEMENT /-7Other n <br /> O <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES 25 ' PIT PRIVY <br /> SEWAGE DISPOSALFIELD - CESSPOOL/SEEPAGE PIT OTHER - <br /> PROPERTY LINES'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 /> EC, k,A L <br /> Irrigation Gravel Pack Depth of Grout Seal di <br /> Cathodic Protection RotaryDisType of Grout <br /> Geophysical <br /> Other Other Information �,✓,., <br /> Geophhysiysi cal �t Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor y'04 v. <br /> Type of Pump j { -T, g.P. <br /> PUMP 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 no "fy them before putting the well in use. The above <br /> information is true to the st of my owledge and belief. <br /> ?RIOR TO GTING A FIN �P I WILL CALL FOR A GROUT INSPECTION <br /> N. <br /> SIGNED s TITLE t <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> I FOR DEPARTMENT USE ONLY <br /> / P-2:1 `pU i T t �A7i©iY <br /> APPLICATION ACCEP DY . �f l ( ,(� DATE '_�(y- 7) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I ,%/FINAL ^INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ` % DATE �. / <br />