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SAN JOAQUIN LOCAL, HEALTH DISTRICT � <br /> FOR OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> � <br /> APPLI!CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> w <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED- Date Issued /a / <br /> { =g (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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �, Phone <br /> 1 <br /> Address /A !l IP City <br /> License �6,YS y6o�i Phone 'f1/7 �7AS— <br /> Contractor s Name //e a ,2 I/r r Co <br /> k <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN %/ RECONDITION / / DESTRUCTION <br /> PUMP [INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> •, Other's/_/ — 3 <br /> DISTANCE TO NEAREST: ,SEPTIC TANK Qa-" SEWER LINES j ) o PIT PRIVY • ►E, <br /> SEWAGE DISPOSAL IELD -�- CESSPOOL/SEEPAGE PIT -8- OTHER <br /> _ PROPERTY. LINF Ja�RIVATE DOMESTIC WELLR PUBLIC DOMESTIC WELL P`1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ( ` <br /> Domestic/public Driven Gauge of Casing /C:a OJI dU d <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ee M-e <br /> Disposal. Other T Other Information '- <br /> Geophysical Surface Seal. Installed <br /> PUMP INSTALLATION: Contractor - I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work ,Dpne, <br /> PUMP .REPAIR: / / State Work Done°. <br /> ,wr i <br /> F DESTRUCTION OF WELL: Well Diameter ~'`�� ,��.r�' 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- ftirnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them beford putting the?.well in use. The above <br /> information is true to the best of my knowledge and belief.?.JI WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN ECTION. e'4__4?1 , <br /> k SIGNED ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT—USE ONLY,,.. <br /> PHASE T , may <br /> APPLICATION ACCEPTED BY DATE /p -?'7 <br /> ADDITIONAL/ COMMENTS: <br /> P. I GRO TNINSPECTION ---PHASy III/I'- AI: INSPRCTP NIr <br /> INSPECTION BY--JAI DATE _INSTE TION_'Bf - DATE I j_­1 <br /> 0/ <br /> i6177 2M <br /> FYHlLc9Fi vs RPZ7Y, 7-7LL sem`._ <br />