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SAN JOAQUIN LOCAL HEALTH DISTRICT r <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. 7��,ss6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,�17-77 <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 and the. Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z1- CENSUS TRACT <br /> Owner's Name 1'' Phone <br /> Address ' City <br /> Contractor's Name License # .dUA Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /X <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 <br /> _ Domestic/private, Drilled Dia. of -Well Casing' V <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 Surface Seal Installed By.: <br /> PUMP INSTALLATION; Contractor ,� f <br /> Type of Pump (/ H.P. / <br /> PUMP REPLACEMENT: / State Work Done <br />--PUMP .REPAIR: / State Work Done - �^�---- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 we11 ''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 y-,knowledge and elief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN O�iV. <br /> SIGNEDTITLE <br /> {D W PLOT PLAN ON RVVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 5-4&-77 , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II/FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BVi, DATE _2— <br /> a <br /> 1177 _ 2M <br />