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111 A& SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fop-, 0 ICE 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 <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 � 6 a? CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> License #I A Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ PUMP REPLACEMENT / <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER DINES PIT PRIVY <br /> s SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER to <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL + <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private � <br /> Drilled - Dia. of Well Casing <br /> _. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1 - <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. D. <br /> f � <br /> PUMP REPLACEMENT: / / State Work Done <br /> _-_ 1 _ l <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTIOR -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 kn dg and-- ief. I WILL CALL FOR A GROUT INSPECTION <br /> "PRIOR TO GROUTING AND A FINAL INSPECT N. <br /> . SIGNED TLE <br /> ( p 'ON RE RSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I DATE 00`/�s" <br /> APPLICATION -ACCEPTED BY <br /> ` ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P 5 NAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY DATEd J T� <br /> 6/77 _ 2Mp, <br /> Fi 1?G[7_ I-74 ---_ - <br />