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U ge <br /> hew <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT © yr <br /> FOR OFFICE USE: 16d T601 E. Hazelton Ave. , ,Stockton, Calif. ,�•srj <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 /> 1^ (Complete In Triplicate) <br /> Application is $ereby 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 .Joaquink <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> 117 <br /> ,Owner's Name Phone. h <br />`,`Address City <br />''. `Contractor#s Name <br /> License 4� 1 Phone <br /> TYPE OF WORK (Check) : NEW-W!LL / ._ DEEPEN / / RECONDITION / /�_. DESTRITCTION I? <br /> 7 '.. PUMP INSTALLATION / / PUMP REPAIR / ../ PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L INES/,012ic PIT PRIVY" <br /> SEWAGE DISPOSAL/IELD/A.r-CESSPOOL/SEEPAGE.IPIT� 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 /> ��� <br /> Drilled Dia. of�We11 Casing ` * <br /> Domestic/private a <br /> Domestic/public Driven Gauge°of Casing <br /> Irrigation Gravel Pack` Depth of Grout Seal <br /> Cathodic Protection _ y RotaryType of Grout <br /> Other Information <br /> Disposal Other <br /> al Surface Seal Installed BY: <br /> Geophysical <br /> : PUMP INSTALLATION: Contractor <br /> 1; Type of Pump - H.P. <br /> ' PUMP REPLACEMENT: / / State Work Done <br /> `s, PUMP REPAIR: State Work Done <br /> { ApproximateDepth 'n <br /> .DES-TRUCTION OF WELL- Well''I Diameter -� -�-`�� <br /> Describe Material and Procedure,— ---_, <br /> I hereby agree to comly <br /> p. �w= th" laws and regula ions of the San Joaquin Local Health District <br /> ��and the State—of lifornia pertaining to or regulating we 11 'construction. Within FIFTEEN DAYS <br /> y'after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ` WELL DRILLERS REPORT of therywell and notify them before putting the well in use. The above <br /> information is trup to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .PRIOR TO GRqjUI3G/AND64 FINAL INSPECTION. <br /> : SIGNED TITLE <br /> f (DRAW PLOT PLAN ON REVERSE Si <br /> 4: R DEPARTMENT USE ONLY <br /> PHASE IDATE , <br /> , APPLICATION ACCEPTED BY `'` <br /> .;;ADDITIONAL COMMENTS: - <br /> G �U INSPECTION r, PHA II FIN INSPECTI <br /> P <br /> v -DATE INSPECTION BY DATE <br /> :INSPECTION BY <br /> L <br /> 1/77 - 2M <br />