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} <br /> '(fl �o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FIS' CE USE: 1601 E. Hazelton,Ave. , Stockton, Calif. <br /> Telephone : (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION" OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issued 1Z -2--717 <br /> (Complete In Triplicate) . <br /> Application is hereby made to the Sant 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 u 9`7 fi -aava - CENSUS .TRACT <br /> Owner's Name APhone <br /> Address / city C-3vw <br /> Contractor's Name License #{ -phone . 67 ? .b <br />'+TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION AL _ <br /> _/ <br /> PUMP INSTLATION / J PUMP REPAIR J / PUMP REPLACEMENT- /_7 <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 Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 5 <br /> Cathodic Protection Rotary Type of Grout M `� <br /> Disposal other Other Information <br /> -Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Donee <br /> PUMP .REPAIR: / / State 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 /> 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 k-nowlyhge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> i� PRIOR TO GROU. ING AND A FINAL I�PEC o <br /> SIGNED TITLERes . <br /> S P OT LAN ON qfEVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z-z <br /> ADDITIONAL COMMENTS: <br /> PHASE II g.W SP TTON P /FINAL .INSPECTTON <br /> INSPECTION BY DATE INSPECTION BY DATE -1 <br /> 0/77 _ 2M <br />