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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -4 ,3 44CENSUS TRACT <br /> Owner's Name 1 •. Phone <br /> Address ` <br /> 0,6 C - !A � City <br /> Contractor's Name -- License # �1,r Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 /> x_ Domestic/private Drilled Dia. of Well Casing ,. <br /> Domestic/public Driven Gauge of Casing �I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information k' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor f , drr.s 1 <br /> -- -- <br /> Type of Pump .r: ,,o H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / State Work Done ' <br /> DESTRUCTION 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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 UTING AND A FINAL NSPE <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON IWVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE fi-to <br /> -77 <br /> ADDITIONAL COMMENTS: 7Z 41, <br /> PHASE II GROUT INSPECTION P E AI/F NAL INSPECTIO - <br /> INSPECTION BY DATE INSPECTION BY DATE 4 <br /> G u 1l,1)r, n..-- � --r i. <br /> 1f77 - 2M <br />