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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> VAPPLICATION FOR WELL CONSTRUCTION OR PUMP-PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ]` 77 <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/LOCATION aW 4P, _ _ _ CENSUS TRACT <br /> Owner's Name ' 1 Phone <br /> • k <br /> Address ---- City S <br /> Contractor's Name s }� License # l y. Phone y— <br /> t <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION REPAIR%{/ PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> n SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> /ernrfi 7.59 PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. 'of Well Casing <br /> Domestic/pub.lic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal p <br /> Cathodic Protection Rotary. Type of Grout ZC <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP .REPAIR: State Work Done 49 44-0y- 0(, <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 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 inotify them before putting the well in use. The above <br /> information 'is true to the best of m owled aand elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUING AND A FINAL INSPEC ON. <br /> SIGNED_ ITLE _ �s� — <br /> (DRAW LO AN ON RE SE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I ! <br /> APPLICATION ACCEPTED BY` DATE 7 aZ� 7-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 71��-177 <br /> 7 i <br />