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[(}vtt l(0 SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOF OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ` <br /> Permit No. ��n. i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM ]DATE ISSUED Date Issued -3�- /- 7 <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 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 12 /0 754ZCENSUS TRACT <br /> Owner's Name , Phone <br /> Address s-6 City <br /> r License #/�^.Phone �"� 217 <br /> Contractor's Name a►- <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN I RECONDITION / / DESTRUCTION <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 O <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �K Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P: to <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work DoneA01A <br /> rrJ s _ <br /> DES-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin`Loca1 Health District <br /> i 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 knowled a and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOTING AND A FINAL INSPE ON. <br /> SIGNED "rt - ITLE <br /> D lMN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED BY C� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR T INSPECTION PHASE IIi/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,r <br /> 3/76 2M <br /> i F P 1LL9A Rnir_ 1-7/4 <br />