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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 117-176b <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7�1J <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 ADDRESS/LOCATION CENSUS TRACT <br /> I <br /> Owner's Name , Phone <br /> • I <br /> Address City o <br /> Contractor'sName License #. Z' /�'% Phone ' <br /> . �i <br /> TYPE-OF—WORK--(—Check)':' NEW"WELT DEEPEN`=/ / "RECONDITION V_7 'DESTRUCTION -/ 7—' <br /> PUMP it I NT <br /> ATION / / PUMP REPAIR/ / PUMP REPLACEME /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S PIT PRIVY <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINWZ PRIVATE DOMESTIC WELL�7 -kPUBLIC DOMESTIC WELL !. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation $I i <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing <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. Z_ <br /> y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP •.REPAIR: _ F y <br /> _ State `Work Done <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 DiJDAYS <br /> and the State of California pertaining to or regulating well'constructfon. .? Within FIFTEEafter completion of my workon a new well, I will furnish the San Joaquin Local Health DiWELL DRILLERS REPORT of the well and no ify them before"putting the well in use. The abo <br /> information is true tothe s of nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T G 'AFI L SP - <br /> SIGNED TITLE 1, , <br /> (DRAW PLOT PLAN ON REVERSE SIDE)`- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , "" <br /> APPLICATION ACCEPTED BY DATE <br />♦ ADDITIONAL COMMENTS: / _r l <br /> PHASE II R NSPECTION PHASE I FIN INSPECTION <br /> INSPECTION BY '`DATE INSPECTION BY DATE 2 <br /> c u 71. lG n __ l--.74 <br />