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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6_3,*"J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUtb Date Issued76S <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. 1862 and the Rules and Regulations of the San -Joaquin Local •Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone ' <br /> 'Address / w CityACANAd <br /> Contractor's Name License` b on%? 4'0 <br /> TYPE OF WORK (Check): NEW WELL /i• --DEEPEN '/'7 RECONDITION %7 DESTRUCTION %j <br /> /e� /� <br /> PUMP INSTALLATION -PUMP REPAIR -/-7—PUMP REPLACEMENT /7 <br /> Other j/% -- <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 Excavatio 9ofN� <br /> Domestic/private Drilled Dia. of Well Casin <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 10 H.P. '–�/ <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> PUMP ,.REPAIR: /_7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . . . . . . <br /> I hereby agree tocomply 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting-the.'.well The above <br /> information is true to the-best -of my.-knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GR0UTTNfZ AND A FINALgNSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ( DATE 54? l�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY i3 DATE <br /> x: X1694 n­ , '71 f <br />