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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -G-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. i <br /> J- <br /> JOB ADDRESS/LOCATION -G� k CENSUS TRACT <br /> Owner's Name , Phone <br /> Address Cit <br /> Contractor's Name License # Phones;F9 3'1.-6 <br /> i <br /> TYPE OF WORK (Check): NEW WELL f / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 WELL PUBLIC DOMESTIC WELL p <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/public Driven Gauge of Casing r <br /> . Irrigation- .—Gravel'Pacle - Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal +. Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �� ��s,,tc„ A0.04-A <br /> "Type. of Pump J H.P. <br /> .,.. 7 <br /> FPUMP REPLACEMENT / / State Work Done r <br /> IPUMP ,.REPAIR: / / 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.•J•oaquin Local Health District <br /> sand 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 wellin 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 _ _� � re�}e _ _ TITLE G� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ICAPPLICATION ACCEPTED BY DATE l <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION P I N INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H61426 Rev. 1--74 1/77: . <br />