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SAN JOAQUIN LOCAL. HEALTH DISTRICT $f r 177 <br /> FOR:OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone :- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THTS,. PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued _�f <br /> ' at , (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 Distract. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name i cel Vr dirt v1- - -- -- Phone "Q 4 <br /> Address Lo E City <br /> Contractor's Name A11651t 6 eq License-ft,3UZ44y Phone e-!Y 51S Z :t.` <br /> _ DESTRUCTION <br /> TYPE OF WORK -(Check) : NEW WELL / / DEEPEN / / RECONDITION /� /_T <br /> PUMP INSTALLATION / / PUMP 4{REPAIR / / PUMP REPLACEMENT /? <br /> ' Other <br /> DISTANCE TO�NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT _I OTHER � <br /> PROPERTY.:LINESQtPRIVATE •DOMESTIC WELL,?D ' ,PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS + <br /> Industrial f Cable Tool Dia. of Well Excavation <br /> Domestic/private .1 Drilled Dia. of Well Casing " <br /> Domestic/public I Driven Gauge of Casing /��J 4� <br /> Irrigation ' . Gravel Pack Depth "of Grout' Seal <br /> Cathodic Protection_` T Rotary Type 'of Grout <br /> Disposals' "!'. Other Other Information <br /> Geophysical, ti Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type oftt.'PumP � u,� . � -- <br /> H.P-. . <br /> PUMP REPLACEMENT / / State Work Done <br /> State=Work-..Done�"�`' - f� =- -# <br /> DESTRUCTION OF WELL,: Well Diameter )[e,,- Approximate Depth ' <br /> Describe'`Material_and Procedur <br /> I herebagree to comply with drl—laws- and regulations of the San Joaquin Local Health District <br /> and the State of California pet tain.in.g.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 no Pify them before putting the .well in .use. . The above <br /> information is .true to the b 5t y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 NG AN A FIN P <br /> SIGNED TITLE - <br /> (DRAW PLOT PLAN ON',REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE , <br />' APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: oo <br /> PPASME GRW INSPEC IO PHASE IIF NAL INSPE9TIQN <br /> INSPECTION BY DATE INSPECTION BY "l DATE14.1% — . 0 ff 6?1,�/ I :� - ; <br /> F ! 1/77 2M. <br />