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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 <br /> Telephone;P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S 6/c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1e2i9- <br /> 1 (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 Joa <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distri <br /> JOB ADDRESS/LOCATION l n,;% �' W,C,1WOocQ— milia, CENSUS TRACT <br /> Owner's Name 6/z+ft"jK Phone /� / / <br /> Address /,Ln,G.(o � wi L!; i 1 W d0� � City c p�c�/ y� <br /> Contractor's Name �1 �B kJi 'tfJ License 0 /±3_723`Phone Y-76; <br /> i d <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN/7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR '] PUMP REPLACEMENT /7 <br /> Other )/ <br /> i <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 i, Cable Tool Dia, of Well Excavation- <br /> Domestic/private 1 Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _� ��z� 2;� Le, <br /> Type of Pump .+ ✓ i4 7l A.P. 7� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /)C/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall 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 <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 andjxelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED %ILTLE ) , <br /> DRAW T P ON REV SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE,PII/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY/ DATE. <br /> r <br />