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W � JOAQUIN LOCAL HEALTH DISTRICT--� <br /> FOE OFFICE USE: l6, E. Hazelton Ave. , Stockton, Carr. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-�53� <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued i{- 96-,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 Jo4quii <br /> County Ordinance. No. 1$62 and the Rules and Regulations of the San Joaquin LqgAl Health District. <br /> JOB ADDRESS/LOCATION S.L.e_ CENpy— <br /> Owner's Name , Phone <br /> Addres <br /> City <br /> Contractor's Name --A) +S )q A ' . � License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/J��/ PUMP REPAIR `/ / PUMP REPLACEMENT /_7 <br /> Other C7 -- <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> y� 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 Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor All- �' � <br /> Type of Pump S� _ H.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 we ll'-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 AND A FINAL INSPECTION. <br /> SIGNED TITLE ftAj <br /> 5 (DRAW. PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III IAL INSPECT N ' <br /> INSPECTION BY DATE INSPECTION BYZl&aDATEZzz <br /> 1177 . _ 2M <br />