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PAP Clek SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 k <br /> T 1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedD£—LL&-4977 <br /> (Complete- In Triplicate) i <br /> Application is hereby made to the San Joaquin Focal 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: 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> t <br /> JOB ADDRESS/LOCATION, a J'X CENSUS TRACT <br /> Owner's Name %, 7' Phone 576/,40' .- <br /> r� tx i <br /> Address c City �7clti' <br /> /ger 5''�1 � - <br /> f � � <br /> Contractor's Name P License #g?� . Phone <br /> TYPE OF WORK-(Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ V1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 14�M;/ CE S�L/SEEPAGE PIT OTHER <br /> PROPERTY LINE.WPRIVATE 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 S <br /> f� <br /> Domestic/public: Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of' Grout Seal <br /> Cathodic Protection 1 _,4._-,Rotary Type of Grout <br /> Disposal x Other Other Information <br /> Geophysical. Surface Seal Installed' B rt5ss <br /> PUMP INSTALLATION: ry Y Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / /`' State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <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 ofkmy 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 GROUT Nf, AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDDI) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,J. DATE 7/* <br /> ADDITIONAL COMMENTS: 1 " <br /> PHASE II INSPECTION PHASE I I/FINAL INSPECTION <br /> r INSPECTION BY DATE INSPECTION BY DATE - - <br /> 0/!77 _ 2M <br />