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S JOAQUIN LOCAL HEALTH DIS`T'RICT <br /> E .l <br /> OFFICE USE: 1601 L. Hazelton Ave. , Stockton, Calit . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No l;1 1a Q0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued %/�-1 7 <br /> (Complete In- Triplicate) <br /> Application s 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 r fa), >,= '_�i ,, ; <br /> / CENSUS TRACT <br /> Owner's Name 4 �l Cid 1? ✓ , �� !..� f.. r�`t Phone ---- - - -- <br /> Address City <br /> Contractor's Name _ 1 cl, License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7' <br /> PUMP INSTALLATION / / PUMP REPAIR /�/ PUMP REPLACEMENT <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 Cable Tool Dia. of Well Excavation <br /> 1c Domestic/private Drilled Dia. of Well Casting _ <br /> T 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 /> Ii <br /> cUMP INSTALLATION: Contractor )4241Zr < C- <br /> Type of Pump <<' .>� , ,, �_ .r ,LJc H.P. v <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done /VCG�� <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 <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 myr owled andelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OU ING AND A FINAL INSPE TI N. <br /> SIGNED ITLE <br /> (/]JRMVPLOT PAN ON RE E SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED BY- <br /> DATE <br /> �l6Z2 7 <br /> ADDITIONAL COMMENTS <br /> PHASE II`GR Z_IN PECTLON-_. .., r,., . .PHASE. II/FINAL I SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 RPv. - I-74 %77 _ 2M <br />