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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOJOCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone :p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS .PERMIT EXPIRES 1 :YEAR FROM DATE ISSUED Date Issued Z .'1�4-7/' <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 Phone dr..? <br /> Address f/ O City E4 C_ <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION _0 PUMP REPAIR / / 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 E CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 /> 791 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -"S e-e 6e- H.P. / <br /> _ i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 <br /> and the State of California pertaining to or regulating well-'construction. Within FIFTEEN DAYS <br /> after completiori� of my work on a new well, I will furnish the San Joaquin Local Health District a f <br /> WELL DRILLERS REPORT of the well and noti.fy'them,before putting. the well in use. The above r <br /> information is true to he best of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING D FINAL SPECTIUN. .v, ^T <br /> SIGNE TITLE <br /> LA <br /> (DRAW PLOT PN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE~ -78 fi <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PUASE ZII/F AL INSPECT ON <br /> INSPECTION BY DATE INSPECTION B DATE <br /> F x 2G7A Dn.. 1 ��777 _ 2M <br />