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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> p , Telephone : (209) 466-6781 <br /> APPLICATION FOR WELLX CONSTRUCTION OR PUMP PERMIT Petmit No. 7- 39� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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/ CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> r '� s�� <br /> Contractor's Name License ib� Phone <br /> Z� <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN/_/ RECONDITION / / DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION ?7TPUMP REPAIR '/—/ PUMP REPLACEMENT /_7 (� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK_S795r- SEWER-LINES.� PIT PRIVY <br /> SEWAGE DISPOS$L ELD CESSPOOL/SEEPAGE PIT/ 0 Ir OTHER <br /> PROPERTY LINE RIVATE DOMESTIC WELL 't PUBLIC DOMESTIC WELL <br /> INTENDED :USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> Industrial Cable Tool %Dia. of Well Excavatioru, <br /> Domestic./private Drilled Dia, of Well Casing <br /> Domes ti-c/pub lic., �* Driven Gauge of, Casing I Z. <br /> Irrigation Gravel Pack Depth .of1Grout Seal a <br /> Cathodic Protection,' Rotary Type of-Grout <br /> Disposal Other Other information ' <br /> Geophysical Surface Seal Installed By: 57 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _Z•rr" H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 4 <br /> Describe Material `arid .Procedure <br /> I hereby agree to comply with .all..,=-and-r.egula.tions-o.f 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI <br /> SIGNED %0,/0mgTITLE <br /> W P i . ILAN ON REVERSE SIDE <br /> FOR D PARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 4 <br /> 9�' <br /> II OUT INSPECTIO - P I /FI INSPECTIO <br /> INSPECTION BY DATE - -Z _ �-INSPECT- ON-BY 4 ATE <br /> 77 / r <br /> 1 2 G✓ Srp 3/76 2r� <br /> 4 6 Rev. 1=74--- - /__ <br />