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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF OFFICE USE 1601 E. Hazelton Ave: , ,Stockton, Calif. DU 0 <br /> Telephone : (209) 466--6781 7-16P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 77 <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 6?3f,/ 7'YJ����.�,Clc - �9P ( > -�t Csa ENSUS TRACT <br /> Owner's Name ,TQC Phone <br /> Address ^ D6 60, " hjK-, - City ` tM'Y <br /> Co' t4actor's Name ,, License # c,2 Q / PhoneS�?�'�j <br /> � i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR] / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK „64QSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERLcJZ-SOO,� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation " "v <br /> Domestic/private Drilled Dia, of Well Casing ZZ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 1/ Gravel Pack Depth of Grout Seal -- <br /> Cathodic Protection t/ 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. <br /> PUMP' REPLACEMENT: / / State Work Done <br />' PUMP ,.REPAIR: / J State Work Done .` <br /> DESTRUCTION 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 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 /> informatio is true t the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ,G OUTING AND A NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT P AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSTIECTIONPHASE <br /> JFIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1177 _ <br /> 0 v T/.7L n___ T 'l/. - <br />