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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF .OeVICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI ermit No. 34 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ,717 <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 � ��d �'/-t CENSUS TRACT -- <br /> Owner's Name - Phone / <br /> Address �`s ' �'� City �w <br /> Contractor's Nam .� , - fi -t .License # 46'01�,� Phone , , <br /> -�f— <br /> TYPE OF WORK (Check) ; NEW WELL /_7 DEEPEN RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> ., Other /_7 — <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 , G <br /> Industrial Cable Took. 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 T Other Other Information <br /> Geophysical `' Surf ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> •` �: <br /> Type of Pump V H.P. <br /> PUMP REPLACEMENT: -y _ / State Work Done � cJ <br /> PUMP ,REPAIR: }/ f State Work Done <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br />`. I hereby agree. - to comply with all laws and regulations of the San Joaquin Local Health bistiict <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 /> information is true to the best of my knowledge and belief. I WILL CAbL FOR A GROUT INSPECTION <br />: PRIOR TO GROUTING AN A FINAL INSP CTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDZY <br /> FOR kEPARTNENT USE ONLY <br /> PHASE 1 - 77 <br /> PLICATION ACCEPTED BY DATE �� <br /> j ADDITIONAL COMMENTS: <br /> f PHASE ROUT INSPECTION PHASE. /FIN IN <br /> R 72 <br /> INSPECTION BY DATE INSPECTION BY DATE "" <br /> F H 1L 9A Dcv_ 1-74 : 1/7.7 _ I <br />