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SAN JOAQUIN LOCAL HEALTH DISTRICT '`,X <br /> FOE OFFICE USE: 1601 E. Hazelton Ave.', Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�_/9--- <br /> ) THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1 �� { (Complete .In Triplicate) <br /> Application is h eby 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local-Health District. <br /> ,JOB ADDRESS/LOCATION C7 CENSUS TRACT <br /> Owner's Name . Phone <br /> F <br /> Address 4 City Zse,- D!V <br /> f Contractor's Name �� � � � /� License # (92j0JOPhone <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION / / DESTRUCTION /-7 <br /> / <br /> PUMP INSTALLATION / —PUMP REPAIR / / JUMP-REPLACEMEN.T /-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 WELL <br /> INTENDED USE j.TY.PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation � <br /> Domestic/private '- f Drilled Dia. of Well Casing _ y <br /> Domestic/public i DrivenGauge of Casing <br /> Irrigation Gravel Pack-k Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal € Other'. Other Information <br /> Geophysical tN: Surface Seal Installed By: _ --- � <br /> PUMP INSTALLATION: Contractor <br /> � <br /> Type H.P.� of Pump �.� _ <br /> PUMP REPLACEMENT.: r'/—,/"I State Work Done \ <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ �� . , } , : - -,�„Approxi.mate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with alllaws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating wel.l'constructi.on. 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 theiwell 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 GROUT INSPECTION <br /> PRIOR TO GRO ING AND A F AL INSPECTION. <br /> SIGNED ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GR INSPECTION PHASE ,OTVI FIN4L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> 77 <br /> 0/77 _ 2M <br /> F N lli9ri fie.. l-7/. <br />