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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone: (209) 466-6781 ;7 a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Issued/d- __, <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. j <br /> - fl 7,1J e ENSUS TRACT D '�170rf 7 <br /> J0 ADDRESS/LOC •TION Ufa �S "'� <br /> Owner's: Name r G !Z S f Phone S j <br /> City <br /> Address' <br /> Al �-c S'i2ytlGl 'W <br /> ,fi 4,r License #&5:740� Phone <br /> Contractor's Name 3 1 <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 Jam' - SEWER LINES /t?l PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation CIO <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/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 By: <br /> - } <br /> PUMP INSTALLATION: Contractor p <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /firf- State Work Done <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 CALL FOR. A GROUT INSPECTION <br /> PRIOR `TO GROUTING AND A FINAL INSPECTION. <br /> . SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> 4 <br /> APPLICATION:ACCEPTED. -BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> HAS II /FIN INSPECTION <br /> DATE INSPECTION BY DATE <br /> INSPECTION-BY".'-` ." - <br /> 6/77 _ 22M <br /> L+ i] '11,70. D 1-7A `" <br />