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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton,` Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> F (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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations ,of the San Joaquin Local Health District. <br /> , <br /> ' JOB ADDRESS/LOCATION /� CENSUS TRACT <br /> k Owner's Name Phone <br /> Address ' �Y� City � � , <br /> Contractor's Name License 4� ,e,&Phone <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> LIV <br /> Other <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 7. Cable Tool Dia. of Well Excavation <br /> ,f/ Domestic/private Drilled Dia. of Well Casing <br /> �.. -_____--Domestic./-publie Driven- ;r -= Gauge'of,`Casirig ' — ' <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 /> PUMP INSTALLATION: Contractor C •L� <br /> E Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done crztl�L -�'• <br /> 1 <br /> !PUMP .REPAIR: / / State. Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II 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 GROUTIrZ AND A FINAL INSP CTIO . <br /> ' SIGNED TITLE _ }�-t.�rn[�1� _ il_ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 2 <br /> (APPLICATION ACCEPTED BY DATE 7-I3-77 <br /> ADDITIONAL COMMENTS: i <br /> PHASE 11 GROUT INSPECTION P SgjT/1I/FL4gL INSPECTION <br /> 'INSPECTION BY DATE INSPECTION BY DATE 7 7� <br /> i <br /> 1177 . 2 <br /> F. H 149A uo.7_ 7-7L. - - - <br />