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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOk�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t <br /> Telephone:' p (209) - 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-<-77 <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 Na. _1862 and the Ru s and Regulations of the San Joaquin Local Health District. <br /> '021-���-(,�� g � _ � � <br /> JOB ADDRESS/LOCATIONell <br /> �� ,�, _ zed u. <br /> F CENSUS TRACT <br /> Owner's Name �':����. <br /> Phone <br /> ' Address C� �o kA <br /> � City <br /> I Contractor's Name /V-4! License # <br /> ITYPE <br /> OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION /__ / DESTRUCTION /-7 <br /> PUMP INSTALLATION 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 WELL1 <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! .-,_ - •Cable Tool .Dia, of Well Excavation <br /> k 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 <br /> Surface Seal Ins_talled_By: _ } <br /> PUMP INSTALLATION: Contractor , . <br /> Type of Pump C <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth p <br /> Describe Material and Procedure I <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 wellin use. The above <br /> information, istrue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A INAL INSPECTION. <br /> SIGNED TITLE v <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY s <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _77 <br /> i <br /> PHASE I GROUT INSPECTION <br /> INSPECTION BY PHAS / INSPECT N <br /> DATE. INSPECTION_BY DATEf!/ <br /> b <br /> E H 1426 Rev. 1-74- , 1/77 ?M <br />