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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO's" OFFICE USE: 1601 E. Hazelton Ave.'; Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17 S <br /> THIS.-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a/� 77 <br /> {r. (Complete In Triplicate) - ., - I r <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::;,r1--86 and the Rules and Regulations of the San Joaquin Loca ealtj► District. <br /> JOB ADDRESS/LOCTION 'j .� �o <br /> CENSUS TRACT. <br /> Owner's Name C�' Phone <br /> Address <br /> City �l7 <br /> Contractor's Name. Licen # b/,21:2-Phone <br /> TYPE OF WORK (Check) : NEW WELL-/g DEEPEN/% RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT- 1-7 ' <br /> Other- "/7/ <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia, of Well Excavation <br /> stic/private �. � Drilled. .Dia. of Well Casing - <br /> Domestic/public. '� Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �rJ <br /> Cathodic Protection:/ Rotary Type of Grout <br /> Disposal Other Other' _Information, <br /> Geophysical Surface RSeal insta'Iled B <br /> PUMP INSTALLATION: Contractor �� v. l <br /> Type".of Pump ! H.P. <br /> r • <br /> PUMP REPLACEMENT: State Work Done " <br /> PUMP .REPAIR: / / ; State Work Done <br /> DES. RUCTION OF WELL:WellDiameter -' <br /> Approximate Depth" <br /> Des cr-ibe-Mater-ial'�-aiid:-,P-ocedure <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 /> FRIOR TO R UNG . D A FINAL INSPECTION. <br /> SIGNED TITLE 3 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY f�� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTIINS ECTION PHA III/F NAL INSPECTION <br /> INSPECTION BY- iDATE INSPECTION BY d DATE - ,j,�-��. <br /> E H 1 +26 PM -7 7- ZPo z 17/{�� �� <br />.- Rev-1-74 - �_2?- 8�rv���� �iY`�fiM. D�� ��5 �-+ r n .�f Z -• 2Nr�"` <br />