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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. tJ�GS <br /> I ',. Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 Joaqu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION r 11 L~�, Pli <br /> CENSUS TRACT <br /> Owner's Name -EFFj'6 447-F APhone <br /> � t <br /> Address (10- - /� l r 11�'le, /C r City - Ckfo N <br /> yr- <br /> Contractor's Name <br /> �(f d�.S , _ _ Lk,6bnse # � Phone � <br /> TYPE OF WORK (Check) : NEW WELL /_7 -DEEPEN /_7 RECONDITION DESTRUCTION /_ <br /> ' PUMP INSTALLATIONS ,1W PUMP REPAIR /—/ '-'PUMP REPLACEMENT /7 a <br /> Other / / "-•ti :`` - - C <br /> DISTANCEJJO NEAREST: SEPTIC TANK '-'iArSEWER 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 ; 4-ft3GONSTRUCTION SPECIFICATIONS <br /> Industrial "CAble. Tool -Dia o -47ell Excavation <br /> Domestic/private Drilled _ Di.a. of Well Casing <br /> Domestic/public t Driven �"Gauge of Casings <br /> Irrigation } Gravel Pack Depth of Grout�Sea1 <br /> Cathodic Protection R.oI Rotary-;�^ Type of Grout <br /> Disposal Other `Oiher Informafi.'on <br /> Geophysics] Sur a �Seal_Ins talled-By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump m g, op H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> )ES•TRUCTION OF WELL: Well Diameter Approximate Depth, <br /> Describe Material and Procedure <br /> r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion ofmy work on a new well, I will furnish. the San Joaquin Local Health District t <br /> 4ELL DRILLERS REPORThof 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 FOR A GROUT INSPECTION <br /> 'RIOR TO GROUT-ING.,-i-ND A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) =� <br /> N. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED. BY> DATE J a 79. <br /> 4.DDITIONAL.COMMENTS:p_- <br /> PHASE II GROUT INSPECTION PHASEJI /FINAI, INSPECTION <br /> INSPECTION BY DATE /Y INSPECTION BY DATE.- - <br />