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SAN JOAQUIN LOCAL, HEALTH DISTRICT p :� <br /> FOR.OFFICE,~USE: ' 1r� 1601 E. Hazelton Ave. , ,Stockton, Calif. , <br /> Telephone: (209) 466-6781 f,' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77 <br /> ' 1 (Complete In Triplicate) <br /> Application is 'hereby made to the-San Joaquin Local Health District for a permit to co&A'ruct`' <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 j . ZA CENSUS TRACT <br /> Owner's Name L Phone <br /> Address - City <br /> ' /`� �� 0 / Phone -- / <br /> Contractor s Name ,�„i62� x <br /> i <br /> TYPE OF WORK (Check) : NEW WELL, <br /> //. .DEEPEN ./_/ RECONDITION / DESTRUCTION / -- <br /> 'PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK. Qp a SEWER LINES g0 , PIT PRIVY �— <br /> SEWAGE 'DISPO�SAL FIELD -- CESSPOOL/SEEPAGE PIT OTHER -- <br /> PROPERTY LINE PRIVATE DOMESTIC WELL ZQ0 ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a <br /> Industrial Cable Tool Dia. of Well Excavation "' <br /> Domestic/private Drilled. Dia. of Well Casing <br /> Domestic/public ;s Driven Gauge of Casing - 944 <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: C <br /> _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> i - <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Dic(meter''­.,_"___ ver. Approximate Depth <br /> " Describe Material and Procedure <br /> I hereby agree to comply with aljl•,laws and regulations of the San Joaquin Local Health District <br /> t 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 th b st f y knowledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING A' CT ION. - rs <br /> SIGNED TITLE' <br /> h <br /> (DRAW -PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> �. PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PjiAS I' GRO T INSPECTION PHASEII/ AL INSPECTI N <br /> jINSPECTION BY ATE 1-7 '7 INSPECTION_BX ].r DATE <br /> l - - f7l7 <br />