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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FO£�;OFFICE USE: ( 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �&d.Ly� <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued �/-1�,�76 r <br /> (Complete In Triplicate) 1 <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 Cr./4t.4,,� y 0 96ENSUS TRACT <br /> Owner's Name Phone 3 L <br /> Address `7- - a .. City I <br /> Contractor's Name ) License 2 i ? Phone <br /> TYPE OF WORK (Check) ; NEW WELL '/� DEEPEN '/ � RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR ( PUMP REPLACEMENT <br /> w I <br /> . 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD C SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DQMSTf C` 'WELI, PUBLIC DOMESTIC WELL <br /> INTENDED USE. TYPE OF WELL ,,. .ayX CONSTRUCTION SPECIFICATIONS p, <br /> Industrial ' Cable Tool Dia: o£ Well Excavation <br /> Domestic/private Drilled Dia. of Wel.l,Casing` f <br /> Domestic/public Driven Gauge of 'Casing \�,a <br /> Irrigation Gravel Pack Depth of Grout Seal v� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical .Surface Seal Installed„ BY.?.,.,...,.,„_,_..__ I <br /> } �I <br /> PUMP INSTALLATIONo Contractor <br /> Type of Pump P. <br /> F <br /> PUMP REPLACEMENT: , J / State Work Done, <br /> PUMP .REPAIR: . '' :r�:- Stated 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 />'fafter 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 truethe-best•of my knowl ge ,,and belief. I WILL CALL 'FOR A GROUT INSPECTION <br />►PRIOR TO GROUTING F AL INS ION. <br /> SIGNED TITLE <br />( DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />{ APPLICATION ACCEPTED BY DATE ' /(-/ Z-7` <br /> ADDITIONAL COMMENTS: �. <br /> PHASE .II GROUT INSPECTION PHASE, 1,11/FINAL INSPECTION <br /> IINSPECTION BY DATE INSPECTION B DATE <br />