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i <br /> ` - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. v" i <br /> Telephone: (204) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued/:2�Z3=744j <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 CENSUS TRACT <br /> Owner's Name h /J� Phone i <br /> AddressCity 45, <br /> Contractor's Name d ^� License #o' hone __-j 7 <br /> I <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION % <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 W <br /> r INTENDED-USE - `- TY-P;E OF WALL - CONSTRUCTION SPECIFICATIONS <br /> Industrial L77' .. Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing C <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth" of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ` t <br /> Disposal Other xOther Information 1 <br /> Geophysical F. Surface Seal Installed By.: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. . j <br /> AA � <br /> LJ- <br /> PUMP REPLACEMENT: State Work Done-, � �� � " <br /> PUMP -REPAIR. T7 State Work Done <br /> -- r <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <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 /> informa 'on i true to the best o my knowledge and belief. I WILL CALF FORFA. GROUT INSPECTION <br /> PRIOR GROUT NC AND A FjINAL Z ECTJL <br /> SIGNED Z TITLE <br /> _ <br /> (DRAW. PLOT PLAN ON REVERSE SIDO.�o <br /> FOR DEPARTMENT USE ONLY L. - <br /> PHASE I ` <br /> APPLICATION ACCEPTED ABY DATE <br /> ADDITIONAL COMMENTS:- - <br /> PHASE II GROUT INSPECTION PHASE Ij FIN INSPECTION r <br /> INSPECTION BY t DATE INSPECTION BY DATE <br /> 6/77 _ <br />