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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: 1601 E. Hazelton Ave.-, Stockton, Calif. <br /> Telephone : (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `f7-V7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .�2 -77 <br /> A_ (Complete -In Triplicate).. <br /> Application is hereby made to the Sari 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, Joaquii <br /> County Ordinance No. 1862 and the Rules and "Reg latinns of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6F_� CENSUS TRACT <br /> Owner's Name � ;)!7367 <br /> Phone r <br /> Address � �� �" � City " <br /> Contractor's N y License ��4��afG Phone �,���� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 /> W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION, SPECIFICATIONS c/y <br /> Industrial Cable Tool 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 /> j Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor � �5ce <br /> Type of Pump <br /> H.-P. <br /> t f <br /> PUMP. REPLACEMENT: state Work Dane <br /> P.UMP ,.REPAIR: / / State Work Done <br /> DES-TRUCTT614 dF_ WtU, Well Diameter Approximate Depth <br /> - Desc-ribe -Material and-Procedure-------------,,.....-- _f T _.� ,� .�.•,.r._ <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 /> information is true to the best of my knowledge and belief. I WILL CALL, FOR A GROUT. INSPECTION <br /> PRIOR TO GROUTING ANP44 LIAL NSP CT ON. . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ; <br /> } PHASE I <br /> APPLICATION ACCEPTED BY DATE 30--1 7 <br /> ADDITIONAL COMMENTS: AF <br /> PHASE II 'GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> f INSPECTION BY DATE INSPECTION BY Z-10DATE 'I-,? -7-7 <br /> of%7 2M <br /> E H 14.2.6.. itev:, 1-74 � , <br />