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T SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE.piF,IGE LASE: ' y 1601 E. Hazelton Ave. , ,Stockton, Calif. f f <br /> Telephone : (209) 466-6781 �/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9qr`-4&1;7 <br /> THIS .PERMIT EXPIRES 1 YEAR 'FROM DATE ISSUED , Date, IssueO/3 S ' <br /> (Complete In Triplicate) <br /> Application is Aereby 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 3o lZe GENSUS TRACT <br /> Z� V <br /> Owner's Name ` •' Phone ? Z �Id <br /> Address �T � 1 � City22! ems <br /> Contractor's -Name License 4� �Phone j'3�, <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN/ f RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES PIT PRIVY ,. r '' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �. <br /> PROPERTY-LINE--PRIVATE DOMES TIC-WELL - - =-PUBLIC -DOMESTIC-WEL <br /> .INTENDEDNUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS +W ' <br /> Industrlal Tool-_. Dia. of Well Excavation <br /> I <br /> Domestic/private Drilled Dia. of Well Casing v <br /> Domestic/public Driven Gauge of Casing (� Q <br /> Irrigation Gravel Pack - -""''Depth of Grout Seal <br /> Cathodic Protection /Rotary' ; n{ ,-Type of Grout <br /> Disposal Other Other Information1 <br /> Geophysical - �a - Surface Seal Installed By: T_ <br /> PUMA' INSTALLATION: Contractor - <br /> Type of Pump __.- _ H.P. <br /> PUMP REPLACEMENT: / / State Work Dane H <br /> PUMP .REPAIR: / / State Work Done <br /> DE5'TRUCT OF WELWe11 Diameterlop <br /> _, ATpro Xate <br /> " <br /> L: epthyN, <br /> A Describe Material and Procedure a <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Ti-strictf <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 Districts ' <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 and belief. I WILL CALL FOR A GROUT INSPECTIO, <br /> PRIOR TO ING AND A FINAL INSPECTION. <br /> SIGNED . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) s�..�� �� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED` BY DATE a. <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHA III/F AL INSPECTION <br />' INSPECTION BY DATE L INSPECTION BY RATE J7S <br /> p4"w , w�5 W15 7 <br />