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SAN JOAQUIN LOCAL HEALTH DISTRICT W <br /> 76—K''OFFICE USE: 1601 E. Hazelton Ave'. , Stockton, Calif. Am <br /> o,� , Telephone: (209) 466-6781 <br /> Iry APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedAN161978 <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 �, �f ,s aZL CENSUS TRACT <br /> Owner's Name pN ,u� Phone <br /> Address <br /> p City �L Q!��,,,4 <br /> 'Contractor's NameA License Y/lZnPhone_ 'J` <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 ' <br /> Other <br /> . DISTANCE TO NEAREST: SEPTIC TANK SC)-'-t SEWER LINES 6d f^ PIT PRIVY <br /> SEWAGE DISPOSALI FIELDCESSPOOL/SEEPAGE PIT �— OTHER <br /> PROPERTY LINE'S PRIVATE DOMESTIC WELL'Za PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <br /> Industrial Cable Tool Dia, of Well Excavation. 'I <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 92 a <br /> C <br /> Irrigation ��/ Gravel Pack Depth- of -Grout Seal V q <br /> Cathodic Protection _ Rotary Type of Grout <br /> .Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor S <br /> Type of Pump - H.P. I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP �.REPAIR: / / State Work Done <br /> I <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 5 <br /> 1 <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 th beds , o` �r.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR Y G D A F N ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 7* � <br /> ADDITIONAL COMMENTS: ( / <br /> PHASE GROUT-INSPECTION' PHASE I/F AL INSPECTION - - <br /> INSPECTION <br /> NSPECTT N - - <br /> INSPECTION BY DATE a _ _INSPECTION BY DATE_.. 7 <br /> I <br /> 5U <br /> F u L 9 h Va,. �i. 1177 _ 2M a <br />