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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> —FOR''OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. a <br /> { Telephone: (209) ' 466-6781 p' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I ate Issued �/ <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 _ /� �� CENSUS TRACT <br /> Qwner's`Name Phone <br /> Address <br /> Contrac-tor. <br /> Name Rn� l ¢ /.T/� y�G/ /1j4i License Phone /, - � <br /> e TYPE OF WORK (Check) : NEW WELL y DEEPEN / / RECONDITION/77� DESTRUCTION -�� <br /> t PUMP IN5 AL ATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> ! � Other <br /> DISTANCE TO NEAREST: -SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT 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 /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of GroutC' �!7 <br /> Disposal-r e F �-�`Other Other Information <br /> Geophysic`al~ ' .M Surface Seal Installed B <br /> S J <br /> PUMP INSTALLATION: Contractor 14 <br /> 4 Type of Pump H.P. <br /> 1 - F <br /> PUMP REPLACEMENT: / / State Work Done <br /> 1 <br /> PUNT -.REPAIR: / / State .Work Done 3 <br /> DESTRUCTION OPF 'WELL: Well Diameter Approximate Depth <br /> +. Describe Material and Procedure <br /> ! I hereby agree -toieomply .wi.th: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 .uywork on. a new well, I will furnish the San.Joaquin Local Health District 2 <br /> WELL DRILLERS REPORT-16ithe well and notify them before putting the -well in use. The above <br /> information istxue.,,to the. best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND A FINAL INSP ON. , <br /> SIGNED TITLE1 <br /> _Y (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> s e FOR DEPARTMENT USE ONLY <br /> PHA S E. I " �."..�„<�.,. ✓ <br /> I DATE <br /> APPLICATION. ACCEPTED BYIf <br /> - - -- - <br /> ADDITIONAL COMMENTS <br /> 'PHASE 11--GROUT.,.INSPECIZON PHASE III/FINAL INSPECTION <br /> kfINSPECTION BY DATE °4INSPECTION BY DATE <br /> F. H 1G26 Ppw_ 1-76 __ <br />