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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . � <br /> THIS PERMIT EXPIRES l YEAR FROM,DATE ISSUED Date Issued 3L2 -77 <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 an�dp the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION G' �1 �, 6CENSUS TRACT <br /> Owner's Name Phone ' 9.9 <br /> Address City <br /> t <br /> Contractor's Name (�� Son License #121 � Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation C <br /> Domestic/private Drilled Dia, of Well Casing 6' <br /> Domestic/public Driven Gauge of Casing 1_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor (� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done palli7WaWN f [ <br /> V <br /> PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 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 GALL FOR A GROUT INSPECTION <br /> PRIOR To GROUTITNG AND A F AL IN PECTION. <br /> SIGNED TITLE. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> 'ADDITIONAL COMMENTS: <br /> PHASE II UT INSPECTION v PHA E Ili/FINAL INSPECTION <br /> 1 INSPECTION BY DATE INSPECTION BY „/�_// DATE d' <br /> E <br /> ! I IZ7 214 <br />