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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF 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.' ���7-77 <br /> (Complete In Triplicate) �. y <br /> Application is hereby made to the San Joaquin Local Health District for a permit toitoristruct <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 Re ulations of the San Joaquin Local Health District. <br /> i �rl?_7--Y <br /> .FOB ADDRESS/LOCATION. d / _ CENSUS TRACT <br /> t Owner's Name Phone <br /> Address l ' Cita' zzzm_� <br /> 4L <br /> Phone.. '1 <br /> Contractor's Name s�l��' icen90 � � <br /> e <br /> TYPE OF WORK (Check) : NEW WELL. /•G/--bEEPEN '/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /!./--PUMP REPAIR/, /= -PUMP REPLACEMENT / T::­-­ <br /> Other <br /> ::-'Other / / '` �— <br /> l l . <br /> DISTANCE TO NEAREST: SEPTIC.TANK &.1,1/1 SEWER LINES PIT' PRIVY f� <br /> SEWAGE DISPOSAL FIELD CESSPOOL%SEEPAGE PIT OTHER <br /> ` PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLi CONSTRUCTION' SP.ECIFICAT.IONS - C. <br /> Industrial ` Cable Tool Dia 'of 'Wel-1,Ej,ecavation- <br /> �mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven` ,Gauge of Casing <br /> Irrigation Gravel' Pack- tf Depth of-"Grout°Seal TG [} <br /> Cathodic Protection ---Rotary 0-- Type of Grout. J �$ A <br /> Disposal >. -NC `� *. Other_ i, � �\ <br /> Other�Inforimati n' <br /> "Geophysical "" Surface Seal Installed By.:, <br /> v J <br /> PUMP INSTALLATION: Contractor f <br /> TypObf Pump .P. <br /> _ e <br /> PUMP REPLACEMENT: / / Stat Work Done <br /> PUMP REPAIR: State Work,Done-,__ l <br /> kDES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 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 GRO NG D A FINAL INSPECT 0 <br /> SIGNED TITLE <br /> ((DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` DATE <br /> i ADDITIONAL COMMENTS: <br /> ° PHASE II GROUT 'INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE- INSPECTION BY DATE <br /> R P lG9A Rav 1-7l. - <br />