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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> F0& OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) f466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -50 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S,�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. <br /> JOB ADDRESS/LOCATION J J r t CENSUS TRACT <br /> Owner's NamePhoneF -f 7,2,e,& <br /> Address S LY:42&LCity <br /> Contractor's Name License it, Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /X/--PUMP REPLACEMENT /_7 <br /> Other-./ / <br /> DISTANCE TO NEAREST: SEPTIC _TANK-_. -SEWER LINES PIT PRIVY <br /> SEWAGE 'IIISPOSA V ELD"F 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 /> Domestic/private Drilied Dia. of Well Casing <br /> Domestic/public -_.D4ven ` � � Gauge of Casing \ <br /> Irrigation Gravel Sack-- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of -Grout <br /> Disposal Other OtherInformation <br /> Geophysical SurfacexSeal Installed By: <br /> Ci A <br /> PUMP INSTALLATION: Contractor <br /> y ;' TYPe of `Pump _ ' ; H.P. <br /> MENT / / State WorkDone <br /> PUMP REPLACE , ' <br /> 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 /> tWELL 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 /> i'PRIOR TO GROUTI G AND A FI L INSPECTION. <br /> SIGNED _ TITLE--,60g.,, <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 6DATE ?% <br />, ADDITIONAL COMMENTS: <br /> PHASE II GROUT I PECTION PHASE II/ , NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> `;2M . <br />