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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&iOFFICE USE:, '~ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> + APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 7w <br /> 7s-.5 981° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -;TDate 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/LOCATION <br /> . i ,L rx,te,., a' ..��, CENSUS TRACT <br /> Owner's Name f" lht Phone Q <br /> Address FFi + , e � City <br /> Contractor's Name r License 'lPhone <br /> 42 <br /> Yir�+riYTfn �rr��:PIM - 1.^Y J <br /> TYPE OF WORM`(Check): NEW WELL % ° DEEPEN '/7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION /SUMP REPAIR / / PUMP REPLACEMENT /7 <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 Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> h Industrial Cable Tool Dia. of Well Excavation rf7 <br /> E .. <br /> L__A,=--Dbmestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> « Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> r . ° Disposal Other Other Information <br /> kGeophysical. Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> LUMP--REPAIR: . /? State--Work Done <br /> ,DEkRUCTION OF WELL: Well Diameter Approximate Depth � <br /> Describe Material and Procedure <br /> I t <br /> t 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIU AND i fINSPECTION.= ,., t! <br /> SIGNED __ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I p <br /> APPLICATION ACCEPTED BY DATE / 1 <br /> ADDITIONAL COMMENTS: _ .g 6 �.. <br /> PHASE II GROUTINSPECTION PHASEAI INSPECTION F <br /> INSPECTION BY A0. DATE IPA -1-7-5— INSPECTION BY DATE <br /> t'E H 1426. . Rev. 1-74 _.. . .- _._a a _ _,_ 7.4- 2M., _ <br />