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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6783 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pe <br /> xmit No. <br /> DEC 2 2 1977 <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 <br /> 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 Dist <br /> ct <br /> , N <br /> JOB ADDRESS/LOCATION D X57 CENSUS TRACT <br /> T ' <br /> Phone — 5 / <br /> Owner's Name o M r1 <br /> City �Ml <br /> Address o <br /> License Phone <br /> Contractor's Name k ,r dt <br /> ���� <br /> tj <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION I / DESTRUCTION 1 <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 Q <br /> INTENDED USE /TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation r <br /> Domestic/private <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 4 Rotary 'Type of Grout <br /> Disposal %Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor IJA,-,k f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: )E State Work Done � � <br /> PUMP REPAIR: / / 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 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 <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 CA L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE _ -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PRASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE �- / �7 <br /> INSPECTION BY DATE d' <br /> INSPECTION BY _ - <br /> 0!77 _ 2M <br />