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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR° OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. C ' .0 <br /> Telephone: (209) 466-6781 ''�� � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�I <br /> THIS PERMIT EXPIRES I' 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. 1.862 and the Rules and Regulations .of the San Joaquin Local Health District. <br /> JOBI�f� NO PLACE Nor2TN o1= /1AkOAj Y L.f1NE GAS T � <br /> ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Ut C, 442 e 1'� -- Phone <br /> Address 3 3© � ,D s: City <br /> UU4U111 rump 1-10. <br /> �^ <br /> Contractor's Name <br /> (Division of San Joaquin Sulphur Go,{) License i1�`�/ 3�Phone369— <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN "/ / trRECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / UMP REPLACEMENT /- <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 T <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ,X 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 /> IN <br /> Geophysical _ -Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . -- — <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State,Work Done <br /> E DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> I <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 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 /> informatio s true to the best of my kno ledge and belief. I WILL CALL FQR A GROUT INSPECTION <br /> PRIOR TO GRO TI D A FIVL NS ^ 30H jouqnrump �^Q� <br /> r SIGNED TITLE (Division of San Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,. - DATE /J- '-77 <br />'. ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '7 <br /> E H 1426 Rou- . 1--74 <br />