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�d�t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFVICE USE: 1601 E. Hazelton Ave. , -Stockton, Calif. <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7-//3/ <br /> _'1` J. 11Q THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedk-?7 <br /> -Sq k- T. I (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 incompliance with Sari Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (.�o y - a � CENSUS. TRACT -- <br /> Owner's Name 77—, C kiPhone " <br /> Address �/ }.. �� j_�} z City <br /> Contractor's Name License # /_��Phoney <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR //k/ 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 _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool -Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing W d <br /> Domestic/public Driven _ Gauge of Casing t, <br /> Irrigation Gravel Pack Depth of Grout Seal f' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION Contractor acme <br /> Type of Pump -_, :.l_ '/ H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /yr/ 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 k <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 a <br /> PRIOR TO GRO TING AND A FINAL INSP C O <br /> SIGNEDITLE <br /> W -PLOT-PtAN ON MXRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ?� <br /> ADDITIONAL COMMENTS: 117 ezz <br /> PHASE II GROUT INSPECTION PHASE'' , 100AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> R H 1426 Rpu. . 1-74 <br />