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SAN JOAQUIN LOCAL HEALTH DISTRICT ° . <br /> FOE OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued4 <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 /> in Local Health District. <br /> County Ordinance No. 1862 and the Rules and .Regulations of the San Joa u <br /> CENSUS TRACT I <br /> .JOB ADDRESS/LOCATION -44 <br /> ,. f <br /> Owner's Name j ) Phone ��— �S <br /> Address City <br /> Contractor's Name License # Phone " <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT 1_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD f 50 _f CESSPOOL/SEEPAGE PIT OTHER a <br /> PROPERTY LINE2r(PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI{NS <br /> Industrial _ �/ Cable Tool Dia. of Well Excavation <br /> 4 � Domestic/private Drilled Dia. of Well Casing n <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ci <br /> Disposal Other Other Information <br /> Surface Seal Installed B <br /> � Geophysical .._ � Y <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump -- --- <br /> PUMP REPLACEMENT: / / 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 /> Rafter 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 thewell in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING F AL_ N ECTION. -. <br /> TITLE <br /> SIGNED <br /> (DRAW-PLOT, PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 1� <br /> PHASE I r �1 ]� DATE — <br /> APPLICATION ACCEPTED BY <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE I ' /FINAL INSPECTION <br /> + INSPECTION BY !j. DATE � INSPECTION BY r DATEy <br /> 6/77 _ 2M <br />