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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �e//.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 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRES S/LOCATION W"- -7- �i /7. �c�L�, CENSUS TRACT <br /> Owner's Name. - Ph one <br /> j 4l <br /> Address °� • , ,-��� City <br /> Contractor's Name 1J,e License Phonel:� <br /> TYPE OF WORK (Check) : . NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / 1/ PUMP REPAIR j5�17PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I ' <br /> SEWAGE DISPOSAL FIEL6 CESSPOOL/SEEPAGE PIT, OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC: DOMESTIC WELL <br /> INTENDEDIUSE TYPE OF WELL CONSTRUCTION; SPECIFICATIONS <br /> T (Industrial Cable Tool Dia. of Well Excavation (,u <br /> o�szic/private Drilled Dia, of Well Casing <br /> Do ttq�ubDriven Gauge of Casing i <br /> Irrigation { Gravel Pack Depth of Grout Seal :.' <br /> Cathodic SProtection Rotary Type of Grout <br /> Disposal ; Other Other Information € <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATiON: . Contractor °a r <br /> { Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State-Work ;Don -" <br /> PUMP .REPAIR: State^Work Done <br /> DESTRUCTION OF WELL: Well Diameter Aroximate Depth <br /> PP F <br /> Describe Material arldfProcedure <br /> i <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 x:-fiegulating 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 notifyt'them before putting the .weft',in use. The above <br /> information is true4o the-best of. my-knowledge and belief, I WILL CAII FOR A GROUT INSPECTION,- <br /> PRIOR TO GROUTING A INAL ECTION. f� f <br /> SIGNED ,� s't� TITLE } <br /> D W PLAN ON KIEWkSE SIDE I "f ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ( DATE <br /> ADDITIONAL !COMMENTS: <br /> PHASE II GROUT INSPECTIODF PHASE III FINAL INSPECTI N /: <br /> INSPECTION BY DATE j' INSPECTION BY DATE /a /7 6 . <br /> 142b x/76 <br /> E z� <br /> Bev. 1-74 <br />