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SAN JOAQUIN LOCAL HEALTH DISTRICT L L tt <br /> FOR OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. 1/I/ /�0 <br /> Telephone : (209) 466-6781 �/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7-/06 <br /> �. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q-/9--77 <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. is applica is made in compliance with San Jo4quin <br /> County Ordinance No. 18622 and the Rule n gulation of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOZV <br /> GE US TRACT <br /> Owner's Name '�' honef <br /> Address ty <br /> Contractor's Name Licensee <br /> i <br /> TYPE OF WORK (Check) : NEW WELL f DEEPEN '/—/ RECONDITI / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR , PUMP REPLACEMENT -7 <br /> Other / / <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. 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 Other10 <br /> Qther Information <br /> Geophysical Surface Surface By: . _. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: �/ // State Work Do <br /> PUMP •.REPAIR: %]y State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <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 INSPECTION. <br /> SIGNED TITLE <br /> i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATES` --�J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E, H 1426 1-7 4 ! � <br /> . <br />