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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. 3 <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued - -� <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 Joaquin <br /> County Ordinance No. -1862 and the Rule and Regulations of the San -Joaquin Local Health District. <br /> I JOB ADDRESS/LOC ION )Z4 5-z TRACT <br /> Owner's Name��Zi <br /> Phones <br /> /tel �i ti <br /> Address <br /> rr �3 Phon <br /> Contractor's Name d-�� e 7 LicensAOK J <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN 17 RECONDITION � DESTRUCTION /7 <br /> PUMP INSTALLATION .PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ► Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled 'Dia. of Well Casing U <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S <br /> R Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' ' <br /> Geophysical Surface Seal Installed.By: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> ' PUMP REPLACEMENT: / / State Work Done od <br /> _71- <br /> REPAIR: State Wo <br /> yz...C4==� <br /> i,DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agreeto comply with all laws and regulations of the San Joaquin Local Health District <br /> land the State of California pertaining to or-regulating well ''construction. Within FIFTEEN DAYS <br /> r 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.... Tile above <br /> information is true to the best-of- my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ,PRIOR TO GR UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE aL.:—_ . <br /> 61 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE , I -14 -77 <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 4 E fi 1426 Ren. 1-74 - <br /> _, 2M.__.. <br />