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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£� OFFICE 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 6-30-76 <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 Regul ions of thee San Joaquin Local Health District. <br /> JOB ADDRES LO TION Ce�z-t�v r CENSUS TRACT <br /> Owner's Name Phoney"`' �f <br /> Address City <br /> Contractor's Na License <br /> 44" Phonie"6 . g6 � <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/7 RECONDITION _ DESTRUCTION f7 <br /> PUMP INSTALLATION/_/ PUMP REPAIR-42K., PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PET OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT. PUBLIC DOMESTIC WELL � G <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS t <br /> k Industrial Cable Tool Dia. of Well Excavation r <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 E Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type ,of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �1 <br /> F PUMP .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 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 7n1 TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) ' / 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> t APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE7-'2-,P- <br /> V Iff ILIA z '7A <br /> + h17 2M <br />