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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . -a -� <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. Th a in compliance with San Joaquin <br /> CPU ty Ox'd'nance No. 1$62 and the Rule g lations f the an Joa Local Health District. <br /> c wa <br /> s W <br /> B ADDRESS/LOCATION CENSUS T4CT <br /> Owner's Name Phone, 2-1177 <br /> Address <br /> Contractor's Name = License Phonek r n-,:�g <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/;07�DEEPEN %/ RECONDITION 1—f DESTRUCTION /_ <br /> PUMP INSTALLATION /T-/�UMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK r SEWER LNES- �IT PRIVY <br /> SEWAGE DISPOSAL FIELD <__0 14- CESSPOOL/SEEPAGE PI 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 /> ---To-me s tic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing _4 <br /> Irrigation Gravel Pack Depth of Grout Se 1 "� <br /> Cathodic Protection 4---Rotary Type of Grout -- <br /> Disposal Other Other Information i-9W -=,e („ <br /> Geophysical ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , •® L, <br /> Type of Pum ,H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> 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 /> inf tion is true to the be.s ..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TING AND N CT <br /> SIG ` TITLE �q f=to a <br /> �- AW- FLIOT PLAN ON REVERSE SIDE) <br /> FOR DEP TMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY DATE <7/I <br /> ADDITIONAL COMMENTS: <br /> PI GRQUIT INSPECTI PHAS III/FINAL INSPECTION <br /> INSPECTION DATE INSPECTION BY DATE <br /> E H 142BY ev. I-74 � <br /> 3/76 2M <br />