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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTO OFFICE USE: 0 1601 E. Hazelton Ave. , Stockton, Calif. 4 <br /> Telephone:' .(209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ- ,5-394)1 <br /> r il' v i <br /> THIS PERMIT"EXPIRES 1 YEAR FROM `DATE ISSUED Date Issued 94,-2,1, i1 <br /> (Complete. In 'Triplicate) � <br /> Application is hereby made to" the Sar: 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 /> x <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name I ` r �[-� Phone '2V <br /> Address 'l: City ' # <br /> Contractor's Name �,�J. License # Phone <br /> TYPE OF WORK (Check) ; NEW WELL '/-7 DEEPEN /_/ RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION /—� PUMP REPAIR /-7 PUMP REPLACEMENT !T <br /> f <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 v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial fI Cabrle Tool Dia. of 'Well Excavation _ <br /> Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge .of-Casing . \n <br /> Irrigation i?. - Gravel- Pack Depth of Grout .Seal <br />'E Cathodic Protection Rotary 'Type of Grout , <br /> Disposal ; Other Other Information <br /> Geophysical A. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor e , <br /> Type of Pump ,: H.P. ' <br /> I;. PUMP REPLACEMENT / / State Work Done <br />'i Ah <br /> PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter l Approximate De `� <br /> t - _ Descrbnerial 'and Proc durV'-X,'�' <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 Word. on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS. REPORT of-i!the well and notify them before putting the..well. in.use.... The above t <br />` information is true' to the-best= of- my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1PRIOR TO Gg2UTING 'AND A VINAL I SPECT �_ V <br /> SIGNED TITLE <br /> (DRAW T PLAN',ON.'NREVERSE SIDE <br /> t` .i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' AC PTED_By,- DATE jJ <br /> ADDITIONAL COMMUTS: !. <br /> I PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -77 <br /> E H 1426,- Reis: 1=-74 � -- <br />