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SAN JOAQUIN LOCAL HEALTH. DISTRICT <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, a � <br /> THIS'PERMIT :EXPIRES° l' YEAR FROM DATE ISSUED ° Date Issued 3_/ 77 <br /> ,; V- .1 (Ciomplete"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-N6.-1862 and tRules and. Regulations of the San Joaquin Local Health District.` <br /> JOB ADDRESS/LOCATION 4F�-u oskvf <br /> Owner's Name �� . �r r . <br /> Phone <br /> Address 4-- 1 �,.. F <br /> City <br /> r <br /> Contractor's <br /> . 5 <br /> * ,. w aP i ✓i �- T License, �iL�/ 2 Phone <br /> TYPE OF WORD (Check) :n�RNEW WELL /Z'"DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> F 4_n Y .• .` PUMP INSTALLATION /Z- -'"PUMP REPAIR' / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE T'O. NEAREST.: !• SEPTIC TANK U 06-$EWER 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 - k-..•• - - 4,.�e Tool- Dia. of Well Excavation <br /> ' Domestic/private ; Drilled Dia, of Well Casing <br /> Domestic ublic � Gauge"' <br /> of Driven Gauge' af Casing OVa <br /> f Irri ation-�­ .,,Gravel Pack Depth -of Grout Seal <br /> Cathod ,c'Protection Rotary Type of: Grout i4� <br /> Disposal* ''; __ ,_ Other, Other Information <br /> Surface- Seal Installed B <br /> PUMP : AL <br /> INSTLATI_ON: ,Contractor <br /> r,{....Type of Pump. _ H.P. <br /> I. <br /> PUMP REPLACEMENT: /% ...State Work Done. _ <br /> .PUMP.!REPAIR: ► » ?MH�� „ State Work Done <br /> DESTRUCTION -OF WELL: Well-Diameter .- - .•• Approximate Depth <br /> Describ7­1e Material and Procedure E <br /> f <br /> I hereby agree to-conply-=with• all laws and regulations of ,the San Joaquin Local Health District <br /> and ,the :State of Cali€ornispertaining toToor-regulata.ng . e11 construction. Within FIFTEEN DAYS <br /> after completion of my work on a new we11;, I will furnish the San Joaqui:n' Loca1 Health District a <br /> WELL DRILLERS REPORT' ofi-the -well• and notify them:-befoAputting the well iniVse. 'The above <br /> information is true to the best o€._my. knowledge and 'belief. - WTL-L CALL FOR A GROUT�INSPECT ION <br /> PRIOR TO GRO N D A FINAL INSP I <br /> SIGNED r°` ! _ TITLE '�- <br /> ,'i(MAW;PLIDT PLAN ON,RE ERSE SIDE) •�;, .,_,_..,....�,� � �, <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY. ' <br /> ' _ � DATE <br /> ADDITIONAL COMMENTS:! . <br /> PHASE 'II-GROUT INSPECTION PHASE III/,FINAL INSPECTION <br /> 1^\`:- *. <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Rev. 1-74 3/76 2M <br />