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FOR OFFICE USE: <br />Date Issued <br />JOB ADORES CENSUS TRACT <br />Owner's Name 7 Phone - ■^'7'/'/ <br />Address City <br />c- <r License Phone Contractor’s Name <br />TYPE OF WORK (Check): <br />DISTANCE TO NEAREST: <br />PUMP INSTALLATION: <br />H.P. <br />PUMP REPLACEMENT:/_/State Work Done <br />PUMP REPAIR:State Work Done <br />DESTRUCTION OF WELL:Approximate Depth <br />p <br />s /?<5 r7$ <br />1/77 . • 2M <br />tzrnce No. T86~2—aod the Rulesand <br />L^I ON £ & <br />information is true <br />PRIOR TO GROUTING At <br />SIGNED <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />/&" <br />/Q"___ <br />Y <br />SEWER LINES PIT PRIVY <br />CESSPOOL/SEEPAGE PIT OTHER <br />PUBLIC DOMESTIC WELL <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation <br />Dia. of Well Casing ___ <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout _____ <br />Other Information ________ <br />Surface Seal Installed -Z' <br />INTENDED USE <br />Industrial <br />Domestic/private <br />DomeStic/public <br />Irrigation <br />Cathodic Protection <br />Disposal <br />Geophysical <br />Well Diameter <br />Describe Material and Procedure <br />and/or install the work herein described. <br />County Ordi: <br />Contractor <br />Type of Pump <br />Permit No. <br />S'--’ JOAQUIN LOCAL HEALTH DISTRICT' <br />1601 . Hazelton Ave., Stockton, Cal <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br />! (Complete In Triplicate) / <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct <br />This application is made in compliance with San Joaquin <br />^Regulations of the San Joaquin Local Health District. <br />ft V <br />NEW WELL /^C DEEPEN_/_/ RECONDITION_/27 DESTRUCTION /~~7 <br />PUMP INSTALLATION PUMP REPAIR /_/ PUMP REPLACEMENT [J <br />Other / / <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__i^ell and notify them before putting the well in use. The above <br />e best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />LNAfc-^NaPECI^ON.^ sx? <br /> TITLE _j <br />(j)RAW PLOT PLAN ON REVERSE SIDE) <br />I?0R DEPARTMENT USE ONLY <br />SEPTIC TANK <br />SEWAGE DISPOSALjFIELD <br />PROPERTY LINE PRIVATE DOMESTIC WELL <br />TYPE OF WELL <br /> Cable Tool <br /> Drilled <br /> Driven <br /> Gravel Pack <br />X Rotary <br /> Other <br />PHASE I X7 /X 7--------------------- <br />APPLICATION ACCEPTED BY ----------------- ----- ------ DAT: <br />ADDITIONAL COMMENTS : <br />PHASE II GROUT INSPECTION PHASE III/FIN/i INSPECTION <br /> INSPECTIQN^BY^ ^^^DATE INSPECTION BY \ VOV, DATE <br />E H 1426 1-7/. <br />^77777