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SAN JOAQUTN LOCAL. HEALTH DISTRICT <br /> FOk.OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: . (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) _._ <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to .coostruct <br /> and/or install the work herein described. This application is made in compliancy with San Joaquin ' <br /> County Ordinance No. 1862 and the Rules and Regulations -of the -San Joaquin Local .Health Distrigt. <br /> JOB ADDRESS/LOCATION . Y'�"`° Fw <br /> . . f _O , � �. �.,� CENSUS TRACT 2y <br /> Owner's Name J Phoneme ' { <br /> Address ' City . <br /> Contractor's Name e <br /> - License �� /`S Phone �40AC <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN /7 RECONDITION /? ' DESTRUCTION-/ f <br /> PUMP INSTALLATION / '°/ PUMP REPAIR / / PUMP REPLACEMENT / ` <br /> Other <br /> DISTANCE TO NEAREST= SEPTIC TANK j , ''SEWER LINES 7, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD z� `'ZESSPOOL/SEEPAGE PIT,i�is;7,��_.OTHXR/)� a,r <br /> PROPERTY LIN »'PRIVATE DOMESTIC WELL �ke-PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF. WELLCONSTRUCTIONSPECIFICATIONS .. <br /> Industrial 4Cable Tool - Dia. of Well Excavations <br /> Domestic/private Drilled Dia. of Well Casing61-� r <br /> t <br /> Domestic/public <br /> Driven Gauge of Casing 114 <br /> beil v. <br /> - Irrigaltion Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> ,_,_Disposal Other . Other Information <br /> Geophysical. Surface Seal,Installed 8 ':" <br /> PUMP INSTALLATION: Contractgr 114.A.Ci xlmx).�,.,Im � <br /> Type of Pump .. H.P...: . <br /> PUMP' REPLACEMENT: / / State Work Done <br /> PUMP. .REPAIR: / / . State Work Done <br /> DESTRUCTION= OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 33 <br /> 1 if,6reby agree to comply with all laws and regulations of the San Joaquin Local Health , i.strict ! <br /> and the State of California pertaining to or regulating well construction. Within AIPTEEN DAYS <br /> after completion of my work on a new well, l 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 GROUTI G AND' A FINAL INSPECTION. F <br /> SIGNED i�1/lil TITLE . i <br /> (DRAW PLOT PLAN ON REVERSE SIDE w, <br /> OR DEPARTMENT USE ONLY <br />'PHASE I :.sy ... <br /> t <br /> APPLICATION: ACCEPTED $ - DATE 1e 7 <br /> ADDITIONAL. COMMENTS <br /> ` PHASE II GROUT INSPECTION . PHAa III&IN6L INSPECTION <br />- INSPECTION BY DATE INSPECTION BY .DATE , <br /> r E H:1426 Rev. 1-74 w - 1/77 2M [ 3 <br />