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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF OFPY'CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 qqdp 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 J�Cp � '64-e CENSUS TRACT <br /> Owner's NamePhone -- <br /> l' D ' i City (�� a. <br /> Address r/� �� : <br /> Contractor s Name License 11��a Phone �� --S�S�'/ <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN / / RECONDITION I I DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP: REPAIR / / PUMP REPLACEMENT <br /> Other <br /> t � <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 r ; ` r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool "f Dia. of Well Excavation <br /> Domestic/private •Drilled Dia. of Well Casing <br /> Domestic/public Driven "I lGauge of Casing I <br /> Irrigation - Gravel Pack-^' `,Depth of Grout Seal <br /> Cathodic. Protection Rotary Type of Grout <br /> Disposal Other Other <br /> Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor <br /> N Type of Pump > F H.P. <br /> PUMP REPLACEMENT: . , x State Work Dorie <br /> i <br /> 'PUMP '.REPAIR: / / State Work Done <br /> IDES:TRUCTION 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 /> 11after 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 wellin use. The above <br /> information is true the best of my knowledge and -belief. I WILL CALL FOR A GROUT INSPECTION <br /> :PRIOR TO R UTING FINAL TNSPECTION. r <br /> 'µ TITLE -- <br /> kSIGNED - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 '77 <br /> ` a <br /> f <br /> APPLICATION ACCEPTED BY DATE <br /> 1ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION' PHASE; II/FINAL INSPECT ON <br /> ' INSPECTION BY DATE INSPECTION BY ? DATE 7 <br /> i <br /> . _ _ 1177 2M <br />