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------------ <br /> p✓�� 3 S JOAQUIN LOCAL HEALTH DISTRICT <br /> OF OFFICE USE: <br /> 1601x. Hazelton Ave. , Stockton, <br /> Telephone: (209). 466-6781 permit No J7—��F�7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issuedflf b- 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 Joic�ir <br /> Count rdinance No. 1862 and the Rule andel Regulations Of a <br /> he n 4oaouin al alt 8j�t <br /> �A4CENSUS TRACT �q <br /> JOB ADDRESS/LOCATION <br /> Owner's Name - Phone <� <br /> 3 city G� <br /> Address ,�License # ��'� Phone <br /> Contractor's Name �l"� c�Z �"'� _ <br /> O <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_/ / RECONDITION DESTRUCTION <br /> DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOI./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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Q Surface Seal Installed <br /> B : <br /> /� <br /> PUMP INSTALLATION: Contractor (/✓ 4 `�' � <br /> Type of Pump Iq nn A H.P. <br /> PUMP REPLACEMENT: State Work Done �e�y <br /> 'T <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 is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AN • NAL INSPECT ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /J pp, <br /> APPLICATION ACCEPTED BY �� � DATE O'J l J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE " 7 <br /> - .. 11-1 - _ - . 6/77 gra <br />