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N JOAQUIN LOCAL HEALTH DISTRIC� �. <br /> FOF OFFICE USE: 16E. Hazelton Ave. , Stockton, Ca�if. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a-63 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 Joaqu: <br /> �ounty Ordinance No. 1862 the Rules and Regula ions of the San Joaquin Local Health District <br /> Ile- <br /> JOB ADDRESS/I,9f r'fi w c CENSUS TRACT <br /> )wner's Name . c�7{ + Phone <br /> address / City <br /> ;ontractor's Name License <br /> :Yl'E OF WORK (Check):- NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /a(j PUMP REPAIR / / PUMP REPLACEMENT <br /> Other �" <br /> )ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ^� r <br /> SEWAGE DISPOSAL FIELD C SS OOL/SEEPAGE PIT/-T'J j"—OTHER <br /> PROPERTY LINE , PRIVATE DOMESTIC WELL 960--�-PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATF NS <br /> Industrial Cable Tool Dia, of Well Excavation ,' '"` <br /> Domestic/private Drilled Dia, of Well Casing / f� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal .,a y— <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> ?UMP INSTALLATION: Contractor -a-tl t S f <br /> Type of Pump <j H.P. ' <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP .REPAIR: / / State Work Done <br /> )ES•TRUCTION 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 <br /> BELL 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 INSPECTIO <br /> SIGNED TITLE <br /> (D PLO L ON REVERSE SIDE) <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> XPPLICATION ACCEPTED BY Ct/< r~ DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECTION P S I /FINAL INSPECTION <br /> INSPECTION BY DATE -\r1-1$ INSPECTION BY DATE — <br /> 77 chi i <br />