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:.� SAN JOAQUIN LOCAL HEALTH DISTRICT 5 �VL,/ <br /> FOFJ,OFFIF,E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6787 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77—f� <br /> TH PERUIT EXPIRES 1 -YEAR FROM DATE .ISSUED Date Issued,,/?, <br /> (Complete In Triplicate) <br /> Application is hereby madeto t fan 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 Ru s a`n Regulations of the San Joaquin Local Health District. <br /> J ADDRESS/LOCATION `�—'IL <br /> 1QSU5 - - <br /> Owner's Name Phone <br /> Address City <br /> r <br /> Contractors Name � � -- License # 3909!yyPhone =,33� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR_ / /_ PUMP REPLACEMENT.''f? <br /> --f .- � -_ Y"•..-,�`.O the r / / � � (` � r�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 CONSTRUCTION SPECIFICATIONS �. <br /> Industrial ::3C Cable Tool Dia. of Well Excavation <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public -_Driven Gauge of Casing /a <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Cew-9 <br /> Disposal _Other _ Other Information <br /> Geophysical Surface Seal Installed By: aCOA&fi3n� <br /> PUMP INSTALLATION i, Contractor <br /> Type of Pump f -- H.P. <br /> �P <br /> PUMP REPLACEMENT: ^ _ �./�/k State Work Done <br /> r 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION_ <br /> PRIOR TO G UTING AND A FINAL, INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY�" T - — -- - DATErZ---- <br /> 4 ADDITIONAL COMMENTS: - <br /> PHASE II gROUT INSPECTION PHASE IIT/ INAL INSPECTION <br /> INSPECTION By , DATE . y INSPECTION BY DATE <br /> I� n TT I I n ,. . Q/77 _ LM <br />