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o� SAN JOAQUIN 'LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zz l3-0&) <br /> {a <br /> fi THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � jj) -77 <br /> 17 (Complete In Triplicate) <br /> Application is he eJy made to the San Joaquin Local Health Distract for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin i <br />.County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION „� CENSUS TRACT �p <br /> i <br /> Owner_Rs-NameZX <br /> -Ph-one <br /> City i <br /> Contractor's Name ` License Phone �fl � � <br /> - i' <br />' Y 'E OF WORK (Check} ; NEW WELL DEEPEN / / RECONDITION /, / DESTRUCTION /_ <br /> r14 PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> / Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ( PIT PRIVY 40 <br /> ! SEWAGE DISP SAL �FIELD�� CESSPOOL/SEEPAGE PIT OTHER <br /> 4' . a PROPERTY LINE ® PRIVATE DOMESTIC WELLV-9-Mr-PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> 'Lndiisttial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled - Dia. of Well Casing <br /> Domestic/-pub.lic _ � _� Driven - Gauge- of--Casing - - <br />� j'Irri gation � Gravel Pack Depth. of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> ±-; Disposa1 Other Other Information <br /> 21 <br /> GeophysicalSurface Seal Installed By: x <br /> PUMP INSTALLATION:,. Contractor <br /> Type of Pump H.P. 1 <br /> PUMP.REPLACEMENT: / / State Wo Done I <br /> PUMP ,.REPAIR: / / State Work Done 3 <br /> h F <br /> DBS:TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ,� ^ <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.o.rmation_is- tr.ue-t.o. the-best-Qf-my-knowle.dge' 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 ,, _ DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE /FIN INSPECTION <br /> INSPECTION BY N1DATE INSPECTION BY TE f <br /> F. N 7 L.9F, uo:. 1-7L <br /> IIZ7 2M <br />