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f� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OWE USE: 1601 E. Hazelton Ave. , Stockton', Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No J7 <br /> { J THIS PERMIT EXPIRES 1 'YEAR FROM DATE' ISSUED Date Issued <br /> e�i� (Complete In- Triplicate) e <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct;' <br /> i and/or inatall the work herein,described. ' This application is made in compliance with SanrJoai <br /> County Ordinance No. 1862 and the Rules and Regulations of the -San Joaquin Local Health Distri <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> I Owner's Name ( LA V ,e r oC (J!m/'i'b( Phone <br /> t <br /> f Address / tC �y�r !?Jr`IftallJol City /Cc <br /> ! <br /> ; Contractor's Name <br /> License (l one <br /> v <br /> TYPE OF WORK (Check) : NEW WELL /J DEEPEN /_7 RECONDITION DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <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 W LL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> �Zc Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public,. Dri-v_eg r f <br /> - �'=Gau a_o _Casing _ <br /> - <br /> Irrigation '''Gravel Pack' Depth of Grout Seal <br /> Cathodic Protection ? Rotary Type of Grout <br /> Disposal ' -e i Other ., Other Information <br /> GeophysicalI Surface Seal"Installed By: <br /> IMP INSTALLATION: s Contrattor ' <br /> Type 6 Pump Cle 4 a yrs' f^!.6/✓ H.P, ' y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done 4,l/�0. <br /> jDES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 <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 owled ah elief. 'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG U ING AND A FINAL INSPE N <br /> SIGNED ITLE ®s <br /> 1 RA PLOr PAN ON REMRSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY` DATE ( �6 U <br /> ADDITIONAL COMMENTS; - <br /> -- <br /> PHASE I RO ,T ZN PECTION.._ , HASE.241 II/.FINAL:I SPECTION�!� <br /> INSPECTION BY- - DATE INSPECTION BY DATE <br />