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0 � � 0_)44P IA4_ '-_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 PERMIT Permit No. _f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedJAN 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION G'r.,O CENSUS TRACT <br /> Owner's Name ,[ 'L Phone IV14 <br /> Address 6 OL a. City <br /> Contractor's Name .n, License �� �� Y Z� Phone !� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION l PUMP REPAIR / / PUMP REPLACEMENT -7 <br /> PUMP <br /> .BR�. <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 /> 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: Cont> acto <br /> Type of Pum H.P. <br /> PUW 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 /> 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 /> PRIOR TO G OU I AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOP, DEPARTMENT USE ONLY <br /> PtLASE I DATE 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYy. DATE -/"/- eP' <br /> 2M <br /> F u '1 L IM Rocs_ . 1_7L �_ <br />