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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: J'�"01601 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 <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 a d the Rules and Regulations of the San Joaquin Local Health District. <br /> o <br /> JOB ADDRESS/LOCATIO f <br /> 74eziCENSUS TRACT <br /> Owner's <br /> Owner's Name � I �+�J �� .�-d¢,1 C��pC�J�E Phone 0 <br /> Address / CJd l 7-16 r-> ' L.(J Coity <br /> Contractor's NameL�l/' License /fit" '-)-3-�&Phone-WW�- <br /> • e <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEP /% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other J-7 <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 Information ' <br /> Geophysical Surface Seal Installed„ By: <br /> PUMP INSTALLATION: Contractor ,;-.- <br /> Type of Pump � -/�/� - - — H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: _- /- / =State Work Done <br /> DES-TRUCTION 'OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <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 FIFPERN DAY§. <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 my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED e TITLE <br /> D W.P PLAN 'ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUlf IN999CTTOW PHASE 4.T11 FINAL INSPECTION' <br /> INSPECTIT BY ATE INSPECTION BY G✓ DATE <br /> E H ., Rev. .1•-74 : 3/76 <br />