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e <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�R `OIFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. 61/1 <br /> Telephone : (209) 466--6781 .7 <br /> APPLICATION FOR WELL CONSTMCTION OR PUMP PERMIT Permit No. <br /> _ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M oDate Issued //'3— <br /> L-©� (Complete In Triplicate) <br /> Application is here y 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 Re ulations 'of the San Joaquin Local Health District. <br /> 51� A4,gA _/pOSf} it' PRL4"4f� lze( Z-0-?-_45D ^fa <br /> JOB ADDRESS/LOCATION S. A ..CENSUS TRACT " <br /> Owner's Name I 's Il Phone � � <br /> to <br /> Address S City. IBJ <br /> License �� Phone <br /> Contractor's Name , l <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION S--/ PUMP REPAIR <br /> Other <br /> DISTANCE-TO NEAREST:----SEPT-IC TANK SEWER LINES PIT PRIVY z <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 Excavatio :' 1?.Q <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/publimc DriveGauge of Casing <br /> Driven <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 B : <br /> PUMP INSTALLATION: Contractor te <br /> Type of Pump 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 /> y <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 Co 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 FO A GROUT INSPECTION <br /> PRIOR TO G UTING AND F AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - l <br /> APPLICATION ACCEPTED BY DATE -,77 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION HAS I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE/ <br /> ,/��j- ` z <br /> � '7 <br />