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? �ezl SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> > FO& OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 77-// <br /> F Telephone: (209) 466-6781• <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,,.;1,6- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued o2_/f+/�+- <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 /> f <br /> JOB ADDRESS/LOCATION, .9 fG % T/S I? `7 F CENSUS TRACT <br /> Owner's Name �// 2/1 - Phone <br /> Address / `�li 2 1 �!�� /, �f �c/ City <br /> Contractor's Name (� /"/���� �. License A ' 6 662 Phone <br /> TYPE OF -WORK (Check): NEW WELL N DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR '/-7 PUMP REPLAcEmENT 17 <br /> Other <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 1 Cable Tool' Dia. of Well Excavation /G <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing . .:4 <br /> �( Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 regu-l.ating.well'construction. Within FIFTEEN DAYS <br /> I 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 and belief. I WILL CALL FORA GROUT INSPECTION <br /> , PRIOR TO GROUTING AND A V_ AL.INSPECTION. <br /> SIGNED (]/ f• TITLE' <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -/ -760 <br /> ADDITIONAL COMMENTS: '�d0 a <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br />