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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> ,.FOE OFFICE USE: e14 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) , 466-6781 c� <br /> APPLICATION FOR WELL CONSTRUCTION OR' PUMP PERMIT Permit No. 77,4,4 ij-' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 � � • A v�� CENSUS TRACT <br /> Owner's Name Phone <br />`'Actress / City Es- 44, <br /> j / License I� Phone J9 <br /> °..� �Y d—�� - -y am,, <br /> Contractor's Name / � E, �1�s l �� <br /> TYPE OF WORK (Check-)-:-,...NEW WELL / / DEEPEN '/—/ RECONDITION /-T DESTRUCTION /-7. <br /> PUMP INSTALLATION jX PUMP REPAIR / / PUMP REPLACEMENT /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 V� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing :r <br /> ;.:• ti ",, Domestic/public Driven Gauge of Casing <br /> " Irrigation Gravel Pack Depth of Grout Seal ,Z <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ,,' �, Other . Other Information <br /> Geophysical C... j-. .� A .,_ Surface Seal Installed By: <br /> .PUMP INSTALLATION: Contractor , <br /> Type of Pump i H.P. <br /> . PUMP REPLACEMENT: / / State -Work. Done <br /> PUMP REPAIR: / / State Work Done <br /> .DES-TRUCTION OF WELL: Well"Diameter, '• `j Approximate Depth <br /> Describe Material and Procedure <br /> .,,- .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 /> '=af.ter 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 /> n€ormation is true �ta the best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> :-PRIOR TO GROUTJNG ANDA FIN INSPECTION. <br /> " SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> r FOR DEPARTMENT USE ONLY <br /> ,.".PHASE I A. - - t - <br /> "APPLICATION ACCEPTED-BY- '=C/_ DATE .�- 7 <br /> �`ADDITIONAL COMMENTS: <br /> PHASE II G T' INSPECTION PHASE I/F . AL JNSPECTION.. <br /> `Y'INSPECTION BY DATE INSPECTION BY DATE L. <br />