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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f(-36/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued AIAR 3 - 1978 { <br /> (Complete In Triplicate) <br /> Application is Hereby made Co 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 s CENSUS TRACT <br /> Owner's Name f Phone s-2�Z-, <br /> -i <br /> Address City ' <br /> Y9 . if 4 <br /> Contractor's Namea License it !y Phone <br /> X <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / RECONDITION / / DESTRUCTION /7 <br /> d <br /> PUMP INSTALLATION / J 7PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK� SEWER LINES -- PIT PRIVY <br /> SEWAGE DISPOSAI�lFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINZt)(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 " __ <br /> , <br /> Domestic/public Driven Gauge of Casing 1��'� �„����/ f <br /> Irrigation .° _— <br /> g Gravel Pack Depth of Grout Seal --- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information J <br /> Geophysical Surface Seal Installed $ <br /> PUMP INSTAL-LATION: 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 <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 bestof y knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING D A NA P CT ION i <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE - � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT 0 PHASE,,,II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY,01- ATE S 5 <br /> i <br /> a <br /> F. H IL2A 1)- l_7I ; 1177 _ 2M i <br />