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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE. 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> 4 Telephone : (209) 466-6781 177.) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> No. <br /> Date Issued l0 X7,77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> k County Ordinance No. 1862 and the Rules and Regu1 tions of the San Joaquin Local Health District. <br /> � <br /> JOB ADDRESS/LOCATION CENSUS TRACT� -- - <br /> Owner's Name <br /> ' Phone <br />�• Address <br /> City 7/.16- <br /> Contractor's Name NI License �f�� Q� Phone <br /> I TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 'ry��j`7" <br /> k Other) / / <br /> I' DISTANCE TOINEAREST: 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 t Cable Tool Dia.-of Well Excavation <br /> Domestic/private s Drilled. Dia. .o? Well Casing K <br /> V: <br /> Domestic/public .Driven-�=---' - `Gauge...of Casing <br /> Irrigation Gravel Pack 'Depthyof Grout Seal <br /> Cathodic Protection Rotary T_ype�of Grout <br /> Disposal #� Othe Other Information ` <br /> Geophy8ical "'""'' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Vf ! _—_ __-.- <br /> -""'TYPoPump <br /> w PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well <br /> 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 istrict <br /> and the State of California pertaining to or regulating well ••construction. Within FIFTEEN DAY <br /> { <br /> , after completion of my work on a new well, I wi11 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 TOG UTING INAL INSPECTION. { <br /> ISIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� DATE <br /> APPLICATION ACCEPTED BY <br /> G ADDITIONAL COMMENTS: PHOS /FIN INSPECTION <br /> PHASE II GROUT IN ECTION DATE <br /> INSPECTION BY DATE INSPECTION BY <br /> i - . 1 _L7 - 2M <br /> V U 1A9A Qatir_ 1_7[, <br />