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SAN,JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: F 1601 E. Hazelton Ave. , Stockton, Calif: <br /> Telephone: (209) •466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP- PERMIT Permit No. 7-7- �3s-�: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued 3-;7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 l�S o CENSUS TRACT <br /> Owner's Name _ �� �'/ C/_��/� r - --- Phone -- <br /> Address <br /> hone --Address _ C/ �l y�' O - //� - -- City <br /> �^- - License # hone <br /> Contractor's Name /e G <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION _ - <br /> ° PUMP INSTALLATION PUMP REPAIR '/ I PUMP REPLACEMENN � " '"' w. <br /> Other <br /> DISTANCE#TO NEAREST: ; SEPTIC TANK SEWER LINES PTT PRIVY : <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITT, OTHER <br /> PROPERTY. LINE .. PRIVATE DOMESTIC WELL PUBLIC`nOMEST,IC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Ind`u`strial I Cable Tool Dia, of Well Excavation <br /> Domestic/private '-�--DrzUled . _. Dia. of Well Casing <br /> Domestic/public Driven Gaugd of-Casing Z,;Z—' <br /> Irrigation Gravel Pack Depth of Grout-Seal <br /> Cathodic Protection _ < Rotary Type of Grout =� <br /> Disposal OtherOther Information t , <br /> _ - Geophysical Surface Seal Installed By- <br /> PUMP <br /> INSTALLATION:'` Contractor 1 C- <br /> Type of Pump <br /> PUMP REPLACEMENT:,I / / State Work Done �l- <br /> _ i <br /> PUMP .REPAIR: / / State Work Done ' <br /> DESTRUCTION OF WELL:, Well Diameter Approximate Depth lett <br /> Describe Material and Procedure <br /> - I <br /> I hereby agree to comply with all laws and regulations of tli 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 11 and notify them before putting the -well in use. The above <br /> information is true to a best of m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING N ECT N. <br /> SIGNED TITLE <br /> ' 7 WRAW PLT PLAN 'ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS':::-- <br /> PHASES IIGROUT INSPECTION -.P S•E-- /FINAL INSPECTION <br /> INSPECTION BY.` - DATE _ ,7. 7 7 INSPECTION.SY Com, DATE <br /> 3/76 2M <br />