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�: _ <br /> CG Hr /04 OC SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> I !i Telephone (209) 466--6781 <br /> `APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.?7_,l/7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �-7 <br /> (Complete In Triplicate) <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 /> i! <br /> JOB ADDRESS/LOCATION ` I / S' e&_ A CENSUS TRACT . <br /> �! _ <br /> -Yi �Clrm o--- � Phone <br /> Owner's Name <br /> Address 14 011 -11 .G - f City <br /> Contractor's Name + License # Phone ' <br /> F . <br /> TYPE OF WORK (Check) : iINEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> IPUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /?<7 <br /> 0 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 <br /> INTENDED USE 0 TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia, of Well. Excavation - <br /> - Domestic/private's Drilled Dia. of Well Casing <br /> Domestic/public ; Driven Gauge of Casing <br /> Irrigation ? Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical I� Surface Seal Installed-By: <br /> ` PUMP INSTALLATION: Contractor .A/ � <br /> i Type of Pump H.P. <br /> , .� 1 <br /> PUMP REPLACEMENT: /k/ State Work Done 1D_ol;p z <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i; 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 <br /> WELL DRILLERS REPORT of the well and no 'fy them bre putting. the well in use.... The above <br /> information is true to .the best of- my now <br /> Zj��be ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO RO NG AND 'yA FINAL I 0 <br /> k SIGNE ITLE � ..� <br /> ( W LOT P ON RE RSE SIDE) <br /> OR. DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED 'BY /D DATE <br /> ADDITIONAL .COMMENTS: a <br /> PHASE II!'GROUT INSPECTION P SE IIT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r 6777 2M <br /> ' F N l '.Ratir '7 1A <br />