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} SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB,,'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .J>� <br /> .. .�..�... THIS PERMIT EXPIRES l'YEAR FROM DATE 'ISSUED Date Issued 1-7�- <br /> 3G'78 ",' (Complete In Triplicate) '(,3 - f70 --0-' <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 .0 made in. compliance with San' Jooquin,. <br />' County Ordinance No. .1862 and the Rules and Regulations of the San :Joaquin•.,Local .Heelth .Distriet. <br /> r <br /> JOB ADDRESS/LOCATION (� �� ' ' � CENSUS TRACT i <br /> Owner's Name, r , <br /> Phone <br /> 1 <br /> Address L l ` ; �. 'City , I <br /> Contractor's Name <br /> . License U Phone <br /> TYPE OF WORK (Check): NEW WELL ;/_7 DEEPEN -/7 RECONDITION /7 DESTRUCTION f� - <br /> PUMP INSTALLATION / / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> Other / / <br /> �^ F <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 Informations <br /> Geophysical Surf ace~'Seal"Installed By <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. <br /> PT7MP <br /> REPLACEMENT: , / // State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br />,DESTRUCTION OF WELL: Well DiameterApproximate 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 anew 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..kr►owledge and belief. I WILL CALL. FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN A' INAL INSP CTION.- ' <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN,-ON, REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I oe <br /> APPLICATION ACCEPTED BY DATE, V-2 y-? <br /> ADDITIONAL'COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II AL INSPECTION <br />: INSPECTION BY DATE INSPECTION BY DATE ` <br />