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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. F <br /> THIS PERMIT EXPIRES l YEAR.. FROM DATE "ISSUED Date Issued / <br /> (Complete In Triplicate) 4 <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 f6A6Aq%W iE CENSUS TRACT <br /> Owner's Name 'V` ,$ e Phone ' <br /> Address <br /> City <br /> Contractor's Name A4 o 8 6G t-t 6 <br /> c• � License hone <br /> TYPE OF WORK (Check): NEW WELL ' DEEPEN /_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR/-7 PUMP REPLACEMENT <br /> Other / / <br /> . s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IT PRIVY <br /> SEWAGE DISP S FIELD /'"`CESSPOOL/SEEPAGE PIT 77�6THER <br /> PROPERTY LIN PRIVATE DOMESTIC WELLS'D PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private V Drilled Dia. of Well "Casing LA <br /> Domestic/public '�"' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 01- <br /> Cathodic Protection <br /> 1-CathodicProtection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface "Seal Installed BY: <br /> PULP INSTALLATION: Contractor Ifs' <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 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 a'. <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 a d belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> .SIGNED E <br /> UWAW-PLOf ON REVERSE SIDE <br /> FOR DE PAR T USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE /-/,Z - 7P <br /> ADDITIONAL COMMENTS: <br /> I GROUT INSPECTIO PHASE. III FINAL INSPECTION <br /> INSPECTION BY DATE nAf INSPECTION BY ' /\_/� DATEND I <br /> F' 74 1A?A a.,.. -71. " 1. he ere <br />