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D <br /> /// SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE. OFFICE USE: `/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _g p By4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ' <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 describ . This application,4s made in compliance wi h San Joaquin <br /> County Ordinance No. 1852 and th R and Regu ations o t San J rict. <br /> JOB ADDRESS/LOCATION 002 � P <br /> CENSUS TRACT _ <br /> Owner's Name Phone e5 C7-40 <br /> Address <br /> Cid <br /> Contractor's Name ��® ' IJ J"/ �5 LicenseV 3� onU /«`► <br /> TYPE OF WORK (Check) . " 1' WELL/- DEEPEN / / RECONDITION / / DESTRUCTION y/7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /� <br /> Other <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ,l <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PLTHiP -REPAIR: j State Work Done �1- <br /> ` <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 /> 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 INSPECTIM <br /> PRIOR TO GR UTING AND A FINAL INSPECTION. -. <br /> SIGNED TITLE <br /> PLAN 'ON C1tSE SI�?�� 1; , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE-� <br /> ADDITIONAL -COMMMNTS: . _ ' <br /> PHASE II GROUT INSPECTION PHASE /-PIDJAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1424e _ . <br /> & v. 1 � 31/76 21C . . <br />