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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 <br /> THIS. PERMIT EXPIRES 1 YEAR FROM:.DATE ISSUED Date Issued %0 -31 77 <br /> (Complete In Triplicate) - I <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 .S Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT 1 <br /> Owner's Name Phone 3- <br /> Address "P � .� City <br /> Contractor's Name r License #,VZj1G'&Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT, OTHER I <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL- <br /> INTENDED <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation T\ <br /> k .._,.Domestic/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 /> Disposal Other Other Information ` <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: C� <br /> Contracto <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />,PUMP REPAIR: / / State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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'constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well., I will furnish the San Joaquin Local Health District as <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 F R A GROUT INSPECTION <br /> PRIOR TO OUTING INAL NSPE TIO <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY- _ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/F AI. INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 6/77 _ 2M <br />