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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OF^. 9E USE: 1601 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 $170 <br /> ; E� (Complete In Triplicate) <br /> Applicationis 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. 102 and the/ Rules Relis of the San Joaquin Local Health District. <br /> / t <br /> JOB ADDRESS/LOCAT a ��.giit' <br /> CENSUS TRACT q©7-: <br /> Owner's Name / r r•P Phone <br /> Address 43-3 ie, City fic&c l4kyzC.! <br /> �j cense,VZ 90 y Phone y� <br /> Contractor's Name !mow _ � <br /> f ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN -/ RECONDITION_/� DESTRUCTION /� <br /> PUMP INSTALLATION / /). ,PUMP REPAIR / / PIMP REPLACEMENT <br /> Other /t.� Ltr, ,I . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,-PIT 'PRLVY f � ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELI,_ _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 6.�omestic/private Drilled Dia. of Well Casing. <br /> 'Doinestic/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 B <br /> PUMP INSTALLATION: Contractor <br /> k0ftga� r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �G , <br /> z <br /> f PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 compleion of my work on a new well., I will furnish the San Joaquin Local Health District .a <br /> WELL DRILLS REPORT of the well an noti them before putting- the well in use..... The above <br /> informatio s true to the best of y k wledge and belief. I WILL C OR A GROUT INSPECTION <br /> FRIOR TO TING F AL S I a <br /> SIGNED ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 6/77 _ 2M <br />