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SAN JOAQUIN LOCAL HEALTH DISTRICT' ' <br /> FOii,--OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 off <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,>-5---V <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date issued <br /> (Complete In. Triplicate) <br /> Application is hereby made,to the Scan 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 Joaqtiin' <br /> County Ordinance No. 1862 -and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name /l _ �9l/✓' /V-) /���5VIII - . Phone <br /> City <br />'Address P �t <br /> '' <br /> Contractor's Name" �/�� ") G , License # 0 2 Phone 2-:5,3�'�.7 <br /> :?. <br /> TYPE OF WORK (Check),. -,WELL /7 .DEEPENS RECONDITION /� DESTRUCTION I T <br /> PUMP INSTALLATION /7 PuN' REPAIR /� PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE'fTO NEAREST: SEPTIC TANK SEWER LINES ,'. PIT PRIVY , (� <br /> �. SEWAGE DISPOSAL FIELD _ ;,CESSPOOL/SEEPAGE PIT ;'OTHER <br /> F PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTICiWELL <br /> INTENDED USE TYPE OF .WRLL GON5TRUGTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation <br />'I ,.--.� Domestic/private Drilled Dia.. of Well Casing <br /> Domestic/public Driven t .� A Gauge of Casing k. <br /> Irrigation - GravellPack _�nep.thorout �ir t <br /> Cathodic Protection, �'.-- Rotor"y Type of Grout <br /> ", Other' Other Information <br /> Disposal �i , . <br /> Geophysical L Surface Seal. Installed 'B <br /> I_U"- INSTALLATION: Contractor <br /> Type of Pump ► H.P. s <br /> PUMP REPLACE State Work Done ► <br /> PiTMP '.REPAIR: / / State Work;. <br /> . Done j <br /> ,.P..,. k ._. <br /> DESTRUCTION OF WELL: Well. Diameter ' ''�^� =_ Approximate Depth <br /> I 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 knowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO TI AL VI INSPECTION. <br /> 'SIGNED TITLE ` a <br /> (DRAW PLOT PLAN ON REVERSE SIDE 1 <br /> t' FOR DEPARTMENT USE ONLY <br /> i'PHASE I <br /> DATE e), f. <br /> APPLICATION' ACCEPTED BY . <br /> .j ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PRASE III ,FINAL INSPECTION, _ <br /> " INSPECTION BY DATE INSPECTION BY DATE �� <br /> 17Y 2M <br /> 4/75 <br />