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p - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT rape Ya <br /> FO> OFFICE USE: <br /> 1601 -E. Hazelton- Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -5-'//'7 K <br /> (Complete In Triplicate) "A) -. a5/-32,Z- b7 <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 s made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations o the San Joaquin Local Health District. <br /> .(..`Z (O i g- 16�ov A94 f <br /> JOB ADDRESS/LOCATION S2 A411 <br /> T CENSUS TRACT <br /> Owner's Name 1 , 0 Phone <br /> AddressW "It Cit <br /> r , <br /> Contractor's Name Lice e hone <br /> r <br /> TYPE OF WORK (Check) : NEW .WELLDEEPEN /_/ RECONDITION / /. DESTRUCTION 17 <br /> f PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> S' l � r,•t I� <br /> DISTANCEI'TOfNEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> iF SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER jd <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION, SPECIFICATIONS <br /> Industrial able Tool Dia. of Well-Excavation'; f . <br /> Domestic/private Drilled Dia. of Well' Casing �! <br /> Domestic/public Driven Gauge of,Casing ! � <br /> irrigation Gravel Pack Depth of Grout Seal 4 <br /> f Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information.. <br /> Geophysical _ Surface Seal Installed Byte <br /> PUMP INSTALLATION: Contractor tiJ <br /> Type of Pump E H.P. <br />'PUMP REPLACEMENT: / / State Work Done <br /> PUMP —.REP—AIR:- / / -State Work Done <br /> I <br /> PE&TRUCTION 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 we11 •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 we and notify them before putting the well. in,use. The above <br /> information rue to the bes of my.knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TO 0 AND FIN SPE ION P 1 <br /> SIGNED TITLE <br /> / <br /> - --(DRAW PLqr PLAN ON REVERSE SID - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> APPLICATION ACCEPTED BY— DATE <br /> ADDITIONAL COMMENTS: <br /> 'PHASE 'll GROUT INSPECTION -- PHASE- II;/FINAL INSPECTION- <br /> INSPECTION BY ..- . . . -DATE : -- INSPECTION BY. DATE <br /> 11.77 . _ 2M <br />