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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoie: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit .No. <br /> ever.r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/o�5 717 <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 Joaqui <br /> County Ordinance. No. 1862 and the Rules- and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRES4S/LOCATION CENSUS TRACT <br /> 4 <br /> Owner's Name cd v i of Phone <br /> Address <br /> '` City <br /> Contractor's Mame ,U —a j2I 4 License #Z40 40 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PU1`iP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK jpj� _ SEWER LINES /622 PIT PRIVY _ <br /> s SEWAGE DISPOSAL FIELD 42f •CESSPOOL/SEEPAGE PIT OTHER' <br /> PROPERTY tINE.0 PRIVATE'-DOMESTIC' WEI:1 PUBT�-rC-DOJ fF,STIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation zati <br /> L.- Domestic/private Drilled Dia. of Well Casing S/ <br /> Domestic T <br /> /public s Driven Gauge of Casing ..Z <br /> F Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _40!,_ Rotary Type of Grout <br /> x Disposal Other _ Other Information <br /> Geophysical Surface Seal Installed By: <br /> I <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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, T will, fY`r-Ash the' Sari Joaquin Local Health District. a <br /> WELL DRILLERS REPORT of the well and notify them befor eputt' ng,the ..well_in use.... The above <br /> information is true to the best` of my knowledge,,- and belief. �I WILL. CAiL FOR A GROUT INSPECTION <br /> ' PRIOR TO GROUTING AND A FINAL INSPECTION. ` . - , 4 . <br /> SIGNED t TITLcs �.�• <br /> (DRAW PLOT PLAN ON REVERSE SID 41 <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION"ACCEPTEDB <br /> ADDITIONAICOMMENTS: <br /> PHASE ITYOUcQINSPECTION <br /> � .,....rt �... ..Y <br /> .•.�. .,��.. ..} D..A-YTE D _.. � <br /> t <br /> PHASE III/FINAL_INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 0/77 <br /> E•-H' 1426-__ .yRy , .1=74 _ �•, r <br />