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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: //1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : " (209) 466-6781 <br /> APPLICATION ,FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. _19' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 7 <br /> (Complete In Triplicate)' ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const uct <br /> and/or install the work herein described. This application is made -in compliance with San Jo4quin <br /> County Ordinance No. 1$62 and the Rules .and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name Phone ' ' <br /> i <br /> Address City <br /> Contractor's Name License ��. �` �s�Phone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 k <br /> PUMP INSTALLATION .AW PUMP REPAIR / / PUMP 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 <br /> 4--"'Dome Stie/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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . _y H.P. <br /> PUMP REPLACEMENT jar State Work Done <br /> PUMP .REPAIR: / / State Work Done- <br /> DESTRUCTION OF WELL: "Well Diameter Approximate Depth <br /> Describe Material and Procedures <br /> I hereby agree tocompwith 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 best, of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br />?RIOR TO GROUJEG AND A FINAL INSPE I N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> PHASE I <br /> FOR-, DEPARTMENT USE ONLY <br /> - <br /> AT ACCEPTED BY DATE �� _77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 'PHASE II/FI AL INSPECTION <br /> INSPECTION BY DATE W . INSPECTION BY DATE 6+7-3=77 <br /> j � � <br /> wKhl Ava <br />