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{ � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E/K <br /> FOk OFFICE USE: 1601 E: Hazelton Ave. , Stockton, Calif. I <br /> Telephone: (209), 466-6781 r/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /(� <br /> ATE ISSUED Date Issued ` -'(l <br /> THIS PERMIT EXPIRES `1 YEAR FROM D /�, <br /> (Complete Ire Triplicate). <br /> Application is hereby made tothe 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 and1the Rules -and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's-Name <br /> Phone (13 CD- --- <br /> Address City . k <br /> Contractor's Named + d 8 c� � - -- License Phone <br /> -3 � <br /> TYPE OF WORK (Check) . NEW,�WELL-K DEEPEN '/_/—RECOND"IT ON %' DESTRUCTION <br /> _PUMP INSTALLATION / / PUMP REPAIR / I PUMP�REPLACEMENT + <br /> Other,l/ / <br /> DISTANCE TO NEAREST: '.SEPTIC TANK Zn_' SEWER LINES PIT PRIVY; - <br /> SEWAGPDISPOSAL FIELD CESSPOOL/SEEPAGE PIT k OTHER <br /> -PROPERTY LINE � PRIVATE DOMESTIC WELL. 4 PUiLIC DOMESTIC WELL � <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> Industrial —_ Cable Tool, : Dia. of Well Excavation <br /> Domestic/private i Drilled --Dia-.- of Well Gas-ing- 4 ; <br /> Domestic/public 1 Driven'rt Gauge of Casing ' <br /> Irrigation Gravel PackF _.Depth of Grout Seal \ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ! Other Other_Information - __ <br /> �..,. - - <br /> Geophysical r Surface Seal.-Installed -B �^Y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H `P. ' , <br /> PUMP REPLACEMENT: / / State Work Done\ !' <br /> PUMP .REPAIR: / / state Work Done --�-- <br /> Y <br /> DES•TRUCTION 'OF WELL: Well Diameter Approximate Depth <br /> { <br /> Describe Material._and_Rrocedure <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 CALL FOR A GROUT INSPECT ON <br /> PRIOR TOG OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> . PHASE I <br /> APPLICATION ACCEPTED BY DATE G <br /> ADDITIONAL COMMENTS: PNT <br /> LINSPECTIOPHASE II GROUT !INSPECTIOINSPECTION BY `DATE �e. INSPECTION B <br /> 7 DATE 4 <br /> 6/77 AM- <br /> �. <br />