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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephor►e: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 677 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued qE I" <br /> (Complete In Triplicate) <br /> Application is hereby made to the San ,Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described.. This application is matte in compliance with San Joaquin} <br /> and Regulations of the San Joaquin <br /> County Ordinance No. 1862 and the. Rules Local Health District. �## <br /> JOB ADDRESS./LOCATION3 r t+ CENSUS TRACT 1 <br /> �L_�Sly <br /> Ownerts Name Phone <br /> Address City Sc�"' r��✓ <br /> - �.o <br /> . , License ���� Phone <br /> Contractor's Name <br /> a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION_/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION / _/ -PUMP REPAIR / / PUMP REPLACEMENT /-T <br /> Other <br /> 1.6 <br /> DISTANCE TO NEAREST: SEPTIC TANK/Z � SEWER LINES 5! PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1.L CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINES PRIVATE DOMESTIC WELLI_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia. of Well Excavation / (nm <br /> _Domestic/private Drilled Dia. of Well Casing \ <br /> Domestic/public Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> Cathodic Protection Rotary Type of Grout —Ce <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 40 <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type,+-of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> I Approximate Depth <br /> DES.TRUCTION OF WELL: Well Diameter <br /> �� /O7j r <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 'mconstruction. 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 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 /> f;PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 1't1'i''L - <br /> APPLICATION ACCEPTED BY C91 <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY /� DATE ,$ -!' <br /> INSPECTION BY DATE / -7 <br /> b/77 2M <br />