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SAN JOAQUIN LOCAL 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�'Z3 , <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 /> � ? `_ zoo� <br /> l / '�,� r�fa l � aa� � Pe7 A���" CENSUS TRACT <br /> JOB ADDRESS LOCATION <br /> Owner!s Name (f;?j /� `� �- Phone <br /> Address d �d7 All City cL ,oe, <br /> Contractor's Name - License # 7;.-S-_P_hone 42)7A 7V <br /> i <br /> TYPE OF WORK (Check) : . NEW WELL / / DEEPEN/_/ -RECONDITION /_/ DESTRUCTION /-J <br /> PUMP, INSTALLATION /}C/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL,/SEEPAGE PIT OTHER <br /> P-ROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ­)c Domestic/private Drilled Dia. of Well Casing V <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. Q <br /> PUMP REPLACEMENT: / / . State Work Done <br /> • I <br /> PUMP'.: z /:/} ''State Work Done <br /> _ - - <br /> DESJRUCTION 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 j <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 in use.. . The above <br /> information is true to the best of --know <br /> I d ea <br /> - nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G AND A FINAL INSP OI� % . <br /> SIGNED / „ TITLE <br /> (D PLOT PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - - 6/77 PM <br />