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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR-AFFICE�USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., 2Z-.Lfi 914,) <br /> Zde <br /> IS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 3 f 77 <br /> (Complete In Triplicate) <br /> Application is herebyto 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 12311 Jb, CENSUS TRACT <br /> Owner's Name Phone , ^� <br /> Address city <br /> Contractor's Name Licens <br /> v � <br /> r. <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN I RECONDITION I f. DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR���-/ , PMP REPLACEMENT <br /> Other ET <br /> DISTANCE T0 "NEAR$�T: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROP§ RTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE g'TYPE OF WELL _ . CONSTRUCTION SPECIFICATIONS \4 <br /> Industrial <br /> "le Tool Dia. o.f Well Excavation <br /> �mestic/private Drilled Dia. ofFWe11 Casing ` \ <br /> Domestic/public Driven Gauge of-Casing .— <br /> Irrigation Gravel Pack Depth of Grout Seal \� <br /> t Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information`s <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> E <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / :/ State Work Done <br />{{{ PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> DescribeaMaterial and Procedure <br />+ I hereby agree to comply witW';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 T6 GjE19 AND A FINAL IN ION. <br /> SIGNED TITLE <br /> DRAW P'L T PLAN 'ON REVERSE SIDE I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED, BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N �, <br /> ` <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> „r <br /> 3/76 <br /> AI2M <br /> V 14 1 L7f Poxy- 1-74 <br />