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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOH,OFFICE USE: ' /1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NoJ;Qy/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> } (Complete In. Triplicate) <br /> Application is hereby made toIthe 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 />• - •�- � /jam . . 1 <br /> JOB_ ADDRESS/LOCATION D INA, CENSUS TRACT <br /> Phone <br /> Owner's Name -VOL C <br /> City - ,, � <br /> %Address Gly <br /> Ai ' <br /> i License # '/�2�W Phone "76 7,61 <br /> Contractor's Name ?��rrl$�� �� _ '`, <br /> TYPE OF WORK (Check): NEW WELL f? DEEPEN '/-7PRECONDITION I-T DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR ff7 PUMP. REPLACEMENT /? <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 A <br /> Industrial } Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> ± Drilled. Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout ' <br /> k Disposal r Other =:' Other Information <br /> Geophysical-- <br /> -'�Sierface`, Seal"Inetailed' B <br /> ::47.PUMP INSTALLATION: Contractor Cc -- H.P. / <br /> Type 6f Pump <br /> PUMP REPLACEMENT: . / / yState Work Done <br /> PUMP `.REPAIR: <br /> / IState Work Done <br /> / <br /> DESTRUCTION OF WELL: WellI?iameter Approximate Depth <br /> Describe Material and Procedure <br /> k �t <br /> I hereby agree to comply with all,-laws and regulations of the San Joaquin Local Health District <br /> sand the State of California 'pert ining 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 knowled elief. I WILL CALL FOR A',GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE N. <br /> SIGNED ITLE <br /> (D W PLOT PLAN ON RSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I DATE l 3` <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I <br /> PHASE II G N ECTI N PRASE III FINAL INSPECTION <br /> I INSPECTION BY r DATE <br /> INSPECTION BY = DATE ' Z� <br /> 2M <br /> 4/75 <br />