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SAN JOAQUIN LOjAL- 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 ` - 1.7-`%4 <br /> (Complete In Triplicate) <br /> Application is Aereby 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.- ��, �f �; ��=-- "';' �a/�,��js c�, ' CENSUS TRACT <br /> Owner's Name ZL1'f/�� 7)�i � Phone <br /> Address /�/ r,i % / '� City <br /> Contractor's Name i,', i.. ( ,{/ %;",r (� : L/ . License fix l/fid/. 1 Phone <br /> TYPE OF WORK (Check) : NEW WELL /7� DEEPEN RECONDITION /-7 DESTRUCTION 1-7 N <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 ,^ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,� r. ' 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 2. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private �_ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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: <br /> PUMP INSTALLATION: Contractor <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 /> 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 GROUTING AND A FINAL INSP CTIO J <br /> SIGNED 'S,. ,t ( ' > , /1 (11��t / -� ._ TITLES C 1 i I"�t_ ��%i{✓/% �- <br /> (DRAW OT PLAN ON REVERSE SIDE) Lv f <br /> OR DEPARTMENT USE .ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -�,�, DATE r - <br /> ADDITIONAL COMMENTS: <br /> PHASE, II,- ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY <,.v DATE / INSPECTION BY DATE. <br /> F 14 14?6 R-a.. 1_74 �� � <br />