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= SAN JOAQUIN LOCAL HEALTH DISTRICT V <br /> FOR OFFICE USE: 160.1 E. Hazelton Ave. , Stockton, Calif. 4 <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � ` <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued A0 '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 Joaquin. <br /> County Ordinance No. 1.$62• andl�the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L -e SUS TRACT <br /> Owner's Name 60S <br /> Phone <br /> '4 <br /> Address City <br /> Contractor's Name C License ���( "Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION_/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 E <br /> Other E/ / <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 t1 Cable Tool Dia. of Well Excavation <br /> Domestic/private H Drilled Dia. of Well Casing �1 <br /> Domestic/public tr Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal N <br /> Cathodic Protection {1 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> k rt f <br />-- PUMP REPLACEMENT: / / State Work Done t <br /> PUMP .REPAIR: / / State Work Done 1 <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- the well in use.. The above <br /> information is true to the b-est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO C.WUTING AN F ALS INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE. I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN P I I/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -- <br /> 6/77 _ 2m <br />