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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 7 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2g;-`1? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedz �d <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 /> / CENSUS TRACT <br /> JOB ADDRESS/LOCATION / �! W <br /> Owner's Name Phone <br /> ylt-4��I <br /> Address City <br /> Contractor s Name <br /> License ����(a�' Phone f1 - <br /> .I <br /> i <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEP / / RECONDITION I=T DESTRUCTION <br /> PUMP INSTAL ION UMP REP / / PLW 1.APLACqENT7- /-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 <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 <br /> Cathodic Protection 'Rotary \Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor J <br />` Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> � " — <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 CAL FOR A GROUT INSPECTION <br /> PRIOR TO GBQUTING ANI)-,A/TjNAI, INSPECTION. <br /> SIGNEDTITLE <br /> DRAW ft T' PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY4/ZTE INSPECTION BY DATE V <br /> 3/76 2M <br />