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ea te l0 04 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR_ OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 3 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �✓"� <br /> �Z (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 �(�� /b� � *J4 CENSUS TRACT <br /> Owner's Name G 9-1- Phone <br /> Address7 J e►�- "A ­.n jCityi4 4a4q, <br /> Contractor's Name License # t j2j-Phone c <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT 1_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 /> Domestic/public Driven Gauge of Casing <br /> ,t 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: Contractor Gc <br /> Type of Pump .., H.P. 3U _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /SC/ State Work Done �* t`L- <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 myed e lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT NG AND A FINAL INSPE �I�w <br /> SIGNED ee TLE <br /> 0 PL ON R ERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I 17 <br /> �� �_� <br /> APPLICATION ACCEPTED BY DATE 1=-=- <br /> ADDITIONAL COMMENTS: <br /> PHASE I 0 T SP CTION P NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY i" -' _ DATE <br /> 6/77 2M <br /> E H 142 <br />