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AN JOAQUIN LOCAL HEALTH DISTR" Y7h. d5•-, 50 <br /> OF, <br /> FOFFICE USE: ItIWI E. Hazelton Ave. , Stockton, C'Nlif. 1'� <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� 73o w <br /> 10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /0 96 7� <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 CENSUS TRACT <br /> Owner's Name Phoneme <br /> Address __( Ca q SS e v AP City 5z z A 6 : <br /> Contractor's Name License U Phone <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION REPAIR / 7 PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK D SEWER LINES S d PIT PRIVY <br /> SEWAGE DISPOSAL FIELD r"Q CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia. of Well Excavation /at •' <br /> _ Domestic/private Drilled Dia. of Well Casing /,7 " <br /> Domestic/public Driven Gauge of Casing4a. . <br /> Irrigation Gravel Pack Depth of Grout Seal $ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: G Lvrw- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. a <br /> _ f <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 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 i true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G NG AND A FINAL CT ION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY } DATE INSPECTION BY `,�. DATE <br /> 0 G �' <br />