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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,;,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif-. <br /> Telephone: (209) 466-6783 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27-, &J <br /> 77- /1/e3 <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE ISSUED Date Issued f-/�7 <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''r <br /> zRules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o ��" CENSUS TRACT <br /> Owner's Name -C-r1JU /.(- ,L Phone <br /> Address � ���. <br /> city <br /> Contractor's Name Z;, L l/ License ` 3 213P h o ne <br /> TYPE OF WORK (Check) : NEW WELL •% DEEP /� RECONDITION /7 /_7 <br /> /YDESTRUCTION <br /> PUMP INSTALLATION % PUMP REPAIR -7 PUMP REPLACEMENT %7 <br /> ti. Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD r CESSPOOL/ EPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC,WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECI <br /> FICA=QNS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r � , <br /> Irrigation Gravel' Pack Depth•_of Grout Seal <br /> Cathodic Protection Rotary Type of Grout T' , <br /> Disposal - Other Other Information # <br /> Geophysical Surface Seal Installed B /9y <br /> PUMP INSTALLATION: Contractor '" <br /> Type .of Pump <br /> PUMP 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 therm 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 'ANDA FINAL INSPECTION. <br /> SIGNED , TITLE <br /> (DRAW PLOT PLAN ON RkVERSE SIDE <br /> FOR PHASE I DEPARTMENT USE ONLY <br />_APPLICATION ACCEPTED BY DATE , //7/771 <br /> ODITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHAU II INAL INSPECTION <br /> 'NSPECTION BY „ DATE INSPECTION BY DATE <br /> VE H 1426 Rev. 1-74� !. 1"r, ALR <br />