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SAN JOAQUIN LOCAL HEALTH- DISTRICT , <br />. FOFr,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Date Issued a - 7� <br /> (Complete In Triplicate) <br /> Application `is hereby made to the San Joaquin Local Health District £or a permit to construct 4 <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. i <br /> ,JOB ADDRESS/LOCATION CENSUS TRACT <br /> 3111 <br /> Owner's Name " }-.r'- � _ Phone <br /> a <br /> City - <br /> 'Address r <br /> Contractor's Name' <br /> r License # Phone <br /> TYPE OF� WORK (Check): NEW WELL fT DEEPEN '/? RECONDITION /�j , DESTRUCTION / T <br /> PUMP INSTALLATION / PUMP REPAIR /_7 PUMP REPLACEMENT <br /> m _.. .r Other;- -/_1- A- <br /> : �- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER .LINES PIT PRIVY „ <br /> -SEWAGEJDISPOFIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE; PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ( ' <br /> .Industrial -7___7_C le Tool s Dia. of Well Excavation W <br /> Domestic/private` ;° Drilled t Dia. of Well Casing <br /> Domestic/public Driven, _ ,. f Gauge of Casing 2 `',1 <br /> Irrigation Gravel Pack .Depth of Grout Seal O <br /> Cathodic Pirctectioh 1 Rotaryl Type o£ Grout <br /> , . _ . <br /> Disposal '^ " 'Other Other Information <br /> -P1 - • , � Surface Seal Installed1j: <br /> Geophysical <br /> PUMP INSTALLATION:; Contractor <br /> H.P. <br /> Yp <br /> T e ,of Pu <br /> �mO , <br /> PUMP REPLACEMENT. .i ;/ / state Work Done <br /> PUMP }REPAIR: 17 (State Work Done <br /> llE&TRUCTION OF WELL: Well.lDiimeter Approximate Depth <br /> + De'scribe 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 weli•'construction. Within FIFTEEN DAYS <br /> after completion of my work on a xiew 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�-Vest-of my knowledge and belief.. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN F AL INSPECTION. <br /> SIGNED ky _ - - _ ...�,�. -; --TITLE" '— <br /> [ DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> r PHASE I . <br /> APPLICATION' ACCEPTED BY <br /> s DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE -II GROUTrINSPECTION PHASE III FINAL ,INSPECTION <br /> INSPECTION BY DATE (I INSPECTION BY DATE L <br /> V ti 7Lh4 In- 7_71. 6/75 2M <br />