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SAN JOAQUIN LOCAL HEALTH DISTRICT ? a 0 �� �� ��� 4/1 <br /> -� <br /> )SOF OPPICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> / Telejihone : (209) 466--6781 �i�/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6 Tr <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 Re_gulatiqns of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A4j DE ry'/2� S % CENSUS TRACT <br /> Owner's Name aPhone 5 _ <br /> Address MMefP 64, / -- City L-©Z?/ <br /> J <br /> Contractor's Name / Licensa ���� ®�7.�Phane '�$ - Z�7 <br /> TYPE OF WORK (Check) : NEW WELL /Y/- DEEPEN/�f RECONDITION / f DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PLTMP REPLACEMENT <br /> € Other <br /> DISTANCE TO NEAREST: SEPTIC TANK fQa SEWER LINES IeZ7 - PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD= _ CESSPOOL/SEEPAGE PIT OTHER <br /> (APRIVATE -DOMESTIC`j;JFI�i PUBLIC-DaMESTIC_WELL- <br /> -INTENDED-USE---- --- -TYPE. OF WELL A\ CONSTRUCTION SPECIFICATIONS <br /> Industrial. ��W Cable Tool Dia. sof Well Excavation <br /> - X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge., of Casing <br /> Irrigation I Gravel Pack Depth,of Grout Seal <br /> Cathodicw-Protection Rotary Type of Grout <br /> Disposal Other Other.Information <br /> Geophysical ' g , Sur-fate Seal. Installed-By: <br /> PUMP INSTALLATION: Contractor ¢ <br /> " Type .of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 ;.11 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 ori '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 GROWING AN IN AL INSPECTION. de <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY G DATE - S <br /> ADDITIONAL COMMENTS: T E <br /> PHASE II GROUT IN PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE - ! INSPECTION BYZ,,,,;7,-DATE- % <br /> s <br /> E . 0/77 - 2M <br />