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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF1ICE.-U-SE: 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 �-;?--/ Y <br /> (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 Joaquii <br /> County Ordinance No. 1862 and. the .Rules and Regulations of, the San Joaquin Local Health 'District. <br /> JOB ADDRESS/LOCATION C�✓1_ r l'C �� �r^c�SP A/r� jeiri15�i�i�n ��f�CENSUS TRACT <br /> � T_...._T <br /> Owner's Name ab . O V-41U�.7� Phone <br /> a Addressl3rx v City <br /> Contractor's Name Q r License # Phone <br /> TYPE OF WORK (Cheek) : NEW WELL /-7 DEEPEN /_/ RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATIION PUMP PA / / P REPLACEMEN /7 <br /> Other % ►' r �`®� U ," ,eh -Ar,' .. Pj <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 able Tool Dia. of Well Excavation p'? er� I— <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Cathodic Protection Rotary Type of Grout de a rig- r <br /> Disposal Other Other Information <br /> —7"Geophysical Surface Seal Installed By: ®, <br /> i vl <br /> PM-fP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done \ <br /> PUMP .REPAIR: / / State Work Done <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 /> sand 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 /> f information is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR. TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE .i <br /> APPLICATION ACCEPTED BY A DATE I ZI 7 77 <br /> �. ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION f PHASE III/FINAL INSPECTION¢ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> _ <br /> E H 1426 Rev- - 1-74 Ch �Q <br /> Cho �c , b/77 2M <br />