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�I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. t <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �9n� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue44N 16 1978 . <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 Joaquin <br /> County Ordinance No. 1 2 I <br /> �p d2tjie Rules- and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> AddressLo <br /> City <br /> Contractor's Name License # Phone d-1-3 S aS <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION /-7 <br /> i <br /> PUMP INSTALLATION / PUMP REPAIR--/. / -PUMP REPLACEMENT /_7 -- <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 /> Domestic/private Drilled Dia, of Well Casing � � <br /> µ <br /> Domestic/public � Driven � GA,uge, ofMCas ing . f <br /> Irrigation Gravel Pack Depth of Grout Seal --- <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information � <br /> Geophysical . <br /> Surface Seal_ Installed By: ra ���5 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' .; <br /> PUMP REPLACEMENT: . <br /> / / State Work Done , <br /> PUMP .REPAIR: / / State Work Done 1 <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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND 4 FINAL INSPECTION. <br /> SIGNED I TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION FliASE III/FINAL INSPECTION <br /> INSPECTION BY DATEZ;e <br /> INSPECTION DATE / ] <br />