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W i d-�� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> . APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N <br /> { THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued77 <br /> f (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 aENSUS TRACT <br /> Owner's. Name Phone <br /> - AddressCity <br /> Contractor's Name License Phone <br /> w �Y -�— trl�� w..� .-�o4r -.ti Men.' yyW�..+..•-sr -: ...- .._. p..�a .may.w.r.- - <br /> __ff _— TION <br /> TYPE OF WORK (Check) : DEEPEN RECONDITION / / DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT -7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES -- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ,- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN "PRIVATE DOMESTIC WELL,<0_&_1PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �► <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal t <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> JPUMP; INSTALLATION: . Contractor <br /> k' Type of Pump H.P. <br /> PUMP REPLACEMENT State Work`Dox e , <br /> .fir �r��_ ��: �.: -,.e..-:::-.. --_ .- �---• � --• �-,�.._.�.:, _ <br /> PUMP .REPAIR: / / State Work Done <br /> y. <br /> DESTRUCTION OF WELL: Well Diameter f Approximate Depth <br /> Describe Material and Procedure <br /> t <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 /> information is true -to the b t f y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G - A FIN SP = 0 . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYgdA� tr DATE <br /> ["ADDITIONAL COMMENTS: f 1 4 { <br /> '=PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSP.E_CTION BY DATE INSPECTION BY _�� DATE d•/ -7� <br /> E H 1+26 Rev. 1-74 <br />