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Co"'P A vow � SAN JOAQUIN LOCAL HEALTH DISTRICT A <br /> FOk OrFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone : (209) x+66--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR,EROM DATE ISSUED <br /> Date Issued -77 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San JoaquinLocal-Health Distxid 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 /> Dk- <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION . <br /> Phone <br /> ; <br /> Owner's Name I <br /> Tl� <br /> City <br /> Address f <br /> � ` r <br /> License # LJ Phone a' . <br /> Contractor's Name 0 / <br /> r• <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /T/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION � PUMP REPAIR / I PUMP REPLACEMENTT <br /> / / <br /> Other f / <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 <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS O <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> T <br /> Cathodic Protection _ Rotary Tye of Grout hex Information <br /> Disposal Other <br /> Geophysical x Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor Ca °ti w H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / ', StateWork Done <br /> PUMP /,C/ State Work Done <br /> Approximate Depth <br /> DESTRUCTIONOF WELL: Well Diameter <br /> Describe Material -and Procedure <br /> I hereby agree '1_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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well'in The above <br /> use. <br /> information is' true to the best-of my kno �1'edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G U ING AND A FI.NA 1�NSPEGT TITLE <br /> SIGNE <br /> (DRAW LO PLAN 0 AVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHA / TNAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 0 <br /> INSPECTION BY DATE; <br /> 6/%7 _ 2M <br />