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= „fSAN JOAQUIN LOCAL HEALTH:DISTRICT <br /> FOR OFFI E USE: L/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> +. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No• <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /O / -79' <br /> (Complete In Triplicate) <br /> r a permit to construct <br /> Application is hereby made to the San Joaquin Local Health ,District fo <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 Joac�ni Local Health District. <br /> � � + �r CENSUS TRACT <br /> JOB ADDRESS/LOCATION � •/ v ,qtr/ <br /> Phone <br /> Owner's Name i <br /> _ City c � <br /> Address <br /> License # l 1'3 2 L1' Phone _ k L7 6 <br /> Contractor's Name <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /�I DESTRUCTION /7 <br /> PUMP INSTALLATION %/ PUMP REPAIR jy/ PUMP REPLACEMENT /? <br /> \Other <br /> / ! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES J 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 <br />` Domestic/private Drilled Dia. of Well Casing <br /> i Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grouts <br /> Disposal Other Other Information <br /> Geophysical Surface 5ea1 Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ✓ H.P. _ U <br /> PUMP REPLACEMENT: / / State Work Done <br /> REPAIR• /}� State Work Done <br /> PUMP ._.,.. <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure <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 <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 "y know edge a d belief. I WILL CALL FOR A GROUT INSPECTION Q; <br /> PRIOR. TO Rfl TING D A FINAL.,4NS9CTI TITLE • <br /> SIGNED. ) i... <br /> W . L PLAN ON F, SE SIDE) <br /> . FOR DEPARTMENT USE ONLY ; <br /> k PHASE I ; DATE /0 <br /> APPLICATION ACCEPTED BY1116/6 <br /> M <br /> ADDITIONAL COMMENTS: <br /> -PHASE JIL/FINAL INSPECTION <br /> ' <br /> PHASE-II-GROUT INSPECTIONN <br /> INSPECTION” BY--. ; <br /> DATE INSPECTION BY � DATE l Q'� -� <br /> 3/76 2m <br /> R°IQ IAM RPv_ 1-74 <br />