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SN JOAQUIN LOCAL. HEALTH DISTRICT <br /> F0E'OFFICE USE: ' 164 Hazelton Ave. , ,Stockton, Ca1ll� 77� �3� <br /> Telephone: (209) 466--6781 <br /> 66 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �J \THIS PERMIT -EXPIRES l YEAR FROM DATE ISSUED Date Issued. <br /> (Complete In Triplicate) <br /> Application is herebyde 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 Regulations of the San Joaquin Local Health Dist#ct. <br /> JOB ADDRESS/LOCATION, CENSUS TRACT <br /> Owner's Name L-EE Phone Q� r� <br /> Address �. LES► .r City <br /> Contractor's Name AT/ / License # 3Phone } -$j r <br /> TYPE OF WORK (Check) : NEW WELL 127 DEEPEN /%. .RECONDITION /�T DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7Other _ <br /> DISTANCE TO NEAREST: SEPTIC TANK ZEE! SEWER LINES ZLee+- PIT PRIVY --- <br /> SEWAGE DISPOSAL FIELD -- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEYO-f PRIVATE DOMESTIC WELL _M ' PUBLIC DOMESTIC WELLT- o� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialb <br /> Cale 'Tool Dia. of'Well Excavation <br /> i ...� - �� <br /> 'Domes <br /> t c/private `Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 22) ;, <br /> X_ 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: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump , - , H.P. o . <br />. PUMP REPLACEMENT,: . / / State Work. Done <br /> PUMP .REPAIR: /- / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> _.� Describe Materiel 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 /> f aft :r 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 tru to t b t knowledge and belief. I WILL- CALL FOR A GROUT INSPECTION <br /> PRIOR T RO G D A.'. N Y - <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPTED BY - /��T DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION' 'PHA5E II / 1NALPECTION <br /> INSPECTION BY DATE INSPECTION BY E <br /> E H 1426 RA,. i_7 A , 1/77 :tA/JAM <br />