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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2j/= 0 <br /> l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,/,__2_j_2,/ <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATJON ��� �v CENSUS TRACT <br /> Owner's Name Phone ,sY5� <br /> Address 54? XL� / City ` <br /> Contractor's Name License #,VA Aj Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT / / <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 WELT, 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 Q <br /> Domestic/public Driven Gauge of Casing \ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 's <br /> Disposal Other Other Information ' <br /> Geophysical Surface <br /> Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: . / / State Work Done pp <br /> PUMP .REPAIR: / / State Work Done <br /> �V <br /> 0 <br /> DESTRUCTION 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 well '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 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 C L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND4 FINAL INSPECTION. lJ - <br /> SIGNED T I T L ✓ - ,,: , <br /> DRAW PIS T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY / j ►} <br /> PHASE Ip DATE <br /> APPLICATION ACCEPTED BY C.✓ /� <br /> ADDITIONAL COMMENTS: <br /> PHASE II- OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> F. i-1 1 L7 h Party- 1-71L <br /> 3/76 2m <br />