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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FOR"OFFICE USE: f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �-_ . <br /> THIS PERMIT EXP IRES M11 YEAR FROM DATE ISSUED ` Date Issued <br /> (Complete In Triplicate) �! <br /> Application✓is hereVy made toIthe 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. 862 a t Rul s nd Re u ations of the San Joaquin Local Health District�,,; <br /> JOE ADDRESS/LOCATION CENSUS TRACT <br /> Ln <br /> Owner's Name Phone9- <br /> . - = - <br /> Address <br /> City�Q �. <br /> _ QieT/ o - -- /, <br /> Contractor's Name �.9fX1 _���y, License Phone <br /> TYPE OF WORK (Check) : NEW-WELL , DEEPEN/ % RECONDITION / / DESTRUCTION-/- Q # <br /> PUMP INSTALLATION / / PUMP REPAIR / ./ PUMP REPLACEMENT-', <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 3 <br /> SEWAGE DISPOSAL FIELD CA—MO—OL/SEEPAGE PIT p OTHER <br /> PROPERTY LINE -- PRIVATE-DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRICTION SPECIFICATIONS <br /> Industrial A Cable Tool Dia, of Well Excavation V, � <br /> Domestic/private Drilled Dia, of Well Casing _i6.21y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - ,-"" d-0 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ^' <br /> Geophysical --.-Surface -Seal Install"ed•B <br /> Ile, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, H.P.f;�c�,! <br /> ' 4 ' <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / State Work Donewil <br /> '- s <br /> DESTRUCTION OF WELL: Well Diameter ` Approximate Depth <br /> Describe Material and Procedure <br /> al <br /> r <br /> I hereby agree to comply with all laws and regulations:,bf% the San Joaquin Local Health District <br /> and the State of California pertaining to or- regulating well -'construction. Within FIFTEEN DAYS <br /> after'vcompletion 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 and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING Ar A FINAL INSPECTION. <br /> SIGNED TITLE s <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY s <br /> PHASE I <br /> APPLICATION14 ACCEPTED BY /Lc d DA E <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROU INSPECTION \N. _: ,y PHASE I/FINAL`INSPECTION <br /> INSPECTION BY DATE INSPECTION EY <br /> 77 <br />