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� SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: P 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 -.�L9 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 ADDRESS/LOCATION Vo jV 64 4 q Al CENSUS TRACT <br /> Owner's Name Phone2cu 2_ <br /> Address VbdU GLilmlyCity �zKe <br /> Contractor's Name , License Phone <br /> TYPE OF WORK (Check) : NEW;WELL k/,_ / _ DEEPEN /% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-. rF PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- <br /> OTHER <br /> :PROPERTY LINE - PRIVATE DOMESTIC WELL ° PUB6IC DOMESTIC WELL <br /> ZNTENDED,USE _OFWELL -&-CONS TRUCT ION SPECIFICATIONS <br /> Indiistrial­ ~' '`'`; Cable Tool Dia. of Well Excavation <br /> I?omes,ticfprivate_A j,_p .} Drilled Dia. of Well Casing <br /> Domestic ublic `* ! <br /> /p -., Driven Gauge of Casing <br /> Irrigation`�7-il Gravel Pack Depth of Grout Sesl Lv ' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information"/ <br /> Geophysical Surface Seal Installed B <br /> t <br /> PUMP INSTALLATION: Contractor ' �! <br /> Type of Pumpr H.P. <br /> PUMP REPLACEMENT: / f 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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN .A FI AL INSPECTION. <br /> SIGNEDk TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> '.S FOR DEPARTMENT USE ONLY . <br /> PHASE I � <br /> APPLICATION ACCEPTED BY _ C�/� r DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE TL C3ROUT­INSPECTION PHASE III/l"INAL IN6PECTI N <br /> INSPECTION BY DATE INSPECTION BY l DATE 7 <br /> . 1/77 ',2M <br />