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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0fi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 <br />! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--161 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5 _Jc'-71` <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 Joaquir <br /> County Ordinance No,. 3.662 and the Rules and Regulations of the San Joaquin Local ,Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT Phone ' <br /> Owner's Name GlJ . Z.3 `S <br /> Address City <br /> Contractor's Nam License U Phone <br /> TYPE OF WORK (Check) : NEW WELL 7 DEEPEN 7 RECONDITION /7 DESTRUCTION w <br /> PUMP INSTALLATION /� �pUMQ REPAIR'/? PUMP REPLACm%7 <br /> Other *4 M — <br /> Ni'i--.t <br /> DISTANCE TO NEAREST: SEPTIC TANK I . SEWER'LINES PIT PRIVY <br /> SEWAGE DISPOSALIFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL I CONSTRUCTION .SPECIFICATIONS <br /> Industrial Cable'Tool- --�- Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> 'Domestic/.public Driven Gauge of Casing <br /> Irrigation tj Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposalr ,t♦ ; .Other, Other Information""- <br /> y Geophysical F Surface Seal •Installed By: <br />€ PUMP INSTALLffIONa <br /> Contractor ; <br /> Type -of Pump <br /> pit <br /> PUMP REPLACEMENT— <br /> State State Work Done <br /> PTV REPAIR: / / State Work Done' i <br /> DES;TRUCTION OF WELL: Well. Diameter Approximate Depth� �` <br /> r Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of th -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 FORA GROUT INSPECTION <br /> PRIOR TO GROU G AND A FINAL I ECTION.... <br /> SIGNED TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � .3 w "� tr <br /> APPLICATION ACCEPTED B DATE � . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION TEM4VOINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> F. R 149x. D. 'I_'7A <br />