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SAN JOAQUIN 'LOCAIr•41EALTH DISTRICT <br /> FOh OFFzCE U E: 1x601 E. Hazelton Ave. , Stockton, Calif. <br /> , <br /> �'r vR • .Telephone : (209) 466-6781. �1f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-1-71 <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 CENSUS TRACT <br /> n � <br /> Owner's Name10-0 A Phone <br /> I <br /> Address 3 city <br /> Contractor's Name License # p Phone ' f(- � j <br /> I <br /> - <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN / / RECONDITION / . /7 DESTRUCT oI N /7 <br /> PUMP INSTALLATION / J PUMP REPAIR-'/ / - PUMP REPLACEMENT /_7 <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK \' SEWER LINES . PIT PRIVY r <br /> SEWAGE DISPOSAL .-FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE - .TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _. Cable Tool Dia.-of -Well Excavation _ t1 <br /> Domestic/private Drilled. Dia, of Well Casing <br /> Damestic/public Driven Gauge of Casing rt <br /> ,Irrigation Gravel Pack Depth of Grout e 1 <br /> Cathodic Protection Rotary Type of Grout._ - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State State Work Don'e <br /> PUMP REPAIR: / / State Work Done -- <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws aid 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 AND A FINAL INSPECTION. <br /> SIGNED TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE ? <br /> ADDITIONAL, COMMENTS: --- r- . ._ <br /> PHAS T INSPECTION PHA /FINAL INSPECTION <br /> INSPECTION BY 4. , DATE fj._. g-._)'- INSPECTION BY DATE <br /> F u -i_'7.. 0�7� <br />