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S . JOAQUIN LOCAL HEALTH DISTRICT <br /> Ok REBICE USE: 1601+... Hazelton Ave. , ,Stockton, Cal_ <br /> IS Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued MAR 3 - 1978 <br /> (Complete In Triplicate) <br /> ?plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquir <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION 6;U o 1 '� �€ CENSUS TRACT <br /> wner's Name � � Cw; s42 ! Phone Q <br /> d d r e s s �N City <br /> ontractor's Name ���� I / U�/pS License/O �;2—S hone�t�� <br /> YPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /7 %P <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> ?STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL—T <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 Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: / / State Work Done <br /> d= <br /> UMP REPAIR: State Work Done <br /> )ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L 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 <br /> ,JELL 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 /> ?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �, f -et TITLE <br /> (DRAW 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 /> 1/77 . 2M <br />