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-_ 3 i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FOk UPFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Tele hone : (209) 466 -6781 <br /> P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssueN161978 <br /> i <br /> (Complete In Triplicate) M <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 /> oro-oz <br /> JOB. ADDRESS/LOCATION - CACENSUS TRACT <br /> Owner's.Name , Phone �� <br /> Address � City #� <br /> Contractor's Name rAl_ )AASZ& '-'[' License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPE RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 4::�'_ SEWER LINES PIT PRIVY 1AI&-- <br /> SEWAGE DISPOSAL FfT.ELII, {CESSPOOL/SEEPAGE PIT OTHER-— <br /> PROPERTY LINE IRIVATE DOMES-TI-C SWELL' UBLIC DOMESTIC WELL-- - <br /> INTENDEDIUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial,, Cable Tool Dia.,ri.of well Excavation <br /> Domestief%private Drilled Dia. of Well Cfsi g <br /> Domestic/public Driven —C-auge---of-Cali g <br /> Irrigation Gravel Pack Depth of,,Grout-`Seal <br /> Cathodic Protection Rotary Type-ofGroit <br /> Disposal Other _.Ottz1Inf•ormation -- <br /> Geophysical Surface`-Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> -Type-of-Pump ,rte H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter' _ Approximate Depth i <br /> Describe Material and Procedure <br /> e [ <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 INSPE TION <br /> PRIOR TO G UTIN • AND A, YINAL INSPECTION. , <br /> SIGNED s TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) n <br /> "' —�--.- '_FOR DEPARTMENT USE ONLY`' <br /> PHASE I ------ ._ <br /> f APPLICATION ACCEPTED BY l : : -- ` '.� -DATE- <br /> �✓ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 17, <br /> 6/77 _ 2M <br /> 1 -7 A <br />