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SAN JOAQUIN LOCAL HEALTH DISTRICT �^ <br /> F0T."OFFICE USE: 16D1 E. Hazelton Ave. , Stockton, Calif. f�'J <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �" <br /> I� THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued 3� 1 4��,76 <br /> I� (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to Construct <br /> j 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 /> E <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br />�. Owner'sName ' <br /> c Phone l Tz <br /> C:[ <br /> A41 <br /> ity <br /> Address a- <br /> Address . E S <br /> k Contractor s Name <br /> License #�6 X37.3 Phone '{ <br /> t TYPE OF WORK -(Check) .� NEW WELL /_7 DEEPEN I / RECONDITION /� DESTRUCTION <br /> ' <br /> PUMP IN'STAL$.ATION / / PUMP REPAIR ' PUMP REPLACEMENT 1_7 <br /> -Other <br /> DISTANCE. TO NEAREST: SEPTIC TANK SEWER-LINES.,e- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE PRIVATE DOMESTIC-WELL -- PUBLIC DOMESTIC WELL <br /> INTENDED •.USE TYPE OF WELL --,. CONSTRUCTION SPECIFICATIONS <br /> rti Industrial Cable Tool Dia. of '"Well Excavation <br /> tDomestic/private, Drilled Dia.,..of Well Casing <br /> Domestic/public Driven Gauge-of Casing <br /> Irrigation Gravel Pack Depth of Grout-Seal. v ' <br /> Cathodic Protection Rotary Type ofiGrout ti <br /> i Disposal Other Other Information <br /> Geophysical. '' Surface Seal. Installed By: <br /> PUMP INSTALLATION: , Contractor <br /> Type of .Pump _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I PUMP`°REPAIR: - State Work Done'44 - � <br /> � DESiRUCTION OF WELL: Well Diameter Approximate Depth <br /> F 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 i <br /> WELL DRILLERS REPORT of the well and notify them before putting-them-well- in use.. . The above <br /> information is true to the-best.of..my-:knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI AN A INSPECT ON. <br /> SIGNED 'a TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTLB�YJ I3f=�LE DATE <br /> , ADDITIONAL COMMENTS: <br /> PHASE II.-GROUT INSPECTION PHASE III F NAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE J <br /> a r' 2M <br /> E H 1426— Rear. 1-"74 -__ <br />