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1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /0 -/.3`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 /> _ A <br /> JOB ADDRESS/LOCATION d CENSUS TRACT <br /> - - <br /> Z;E L <br /> Owner's Name . Phone - �� <br /> Address <br /> City <br /> Contractor's Name <br /> _ License �6pL()Phone <br /> TYPE OF WORK....(..Cher _ <br /> DE-S'R�}C��-0N- -PUMP INSTALLATION % PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ` <br /> i <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 /> Domestic/private Drilled Dia, of We11 Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Groui,Seal <br /> Cathodic Protection � Rotary Type of Grout`` ' <br /> Dispasal '' ;r,_ Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor fir <br /> Q..3 Type of Pump' <br /> �. H,P. <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP .REPAIR: ,�, ` <br /> t / /, State Work Done <br /> DESTRUCTION OF WELL: -Well Diameters N Approximate Depth <br /> Diescribe�Material-,.and Procedure <br /> I hereby agree to comply with all laws and regulations of theiSan Joaquin Local Health District <br /> and the State of California pertaining to or regulating well '':constru`ction. 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 GRQUTING AND WIN , INSPECTION, <br /> SIGNED _ TITLE, <br /> r (DRAW PLOT PLAN ON REVERSE SI ) <br /> PHASE T FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S I/FIN INSPECTI N , <br /> INSPECTION BY DATE INSPECTION BYW , E '2 ` <br />