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d !d { [ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI E USE: 1601 E. Hazelton Ave. , Stockton,t ckton, Calif. k <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /p TIX <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/S- <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 RuI_es and Regulations of the San Joaquin Local Health District. ` <br /> JOB ADDRESS/LOCATION Zee a VL /y,E7 CENSUS TRACT <br /> Owner's Name �� Phone <br /> Address / <br /> �- 1e mj9t:' City r <br /> Contractor's Name- License # ..2 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <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 V <br /> Domestic/public Driven Gauge of Casing f <br /> = Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout NZ , <br /> Disposal Other Other Information <br /> —Geophysical <br /> Surface Seal Installed. BY......_._.._._. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 4LC� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:. " State-Work Done <br /> DESTRUCTION OF WELL: Well .Diameter Approximate Depth <br /> Describe Material and Procedure 4 <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'constructi.on. 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 wledge an elief. I WILL CALL"kFOR A GROUT INSPECTION <br /> PRIOR TO T NG AND A FINAL I C ION. <br /> SIGNED f TLE h <br /> (D W POT PLAN ON RE E ASIDE) s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> , ._..__..._ DATE /y- -,77 <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /® <br /> 72 <br /> � _ _ <br />