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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT-. 05TICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209). 466-6781 <br /> u APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED -Date Issued <br /> i . (Complete In Triplicate) <br /> Alic�ition is hereby eby made to the San Joaquin Local Health District for a permit' to construct <br /> and/or installthe 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 NameA lf�l Phone Ll <br /> Address City <br /> yvr <br /> Contractors Name , License Phone <br /> k <br /> TYPE OF-WORK-(Check)- NEW--WELL��-DEE-PEN�-/ /----RECONDITION-/-�/- DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / ' PUMP REPLACEMENT <br /> Other 1/ / <br /> DISTANCE TO NEAREST: _SEPTIC TANK r SEWER LINES PIT PRIVY <br /> 4 SEWAGE �DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> " PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDEDUSE ".i t TYPE OF WELL CONSTRUCTION SPECIFICATIONS_ <br /> Industrial Cable Tool Dia. of WellExcavation ri <br /> _ p� <br /> C rpomestic/priva-te - t Drilled Dia, of Well Casing " t7. !V <br /> Domestic/public t ` ` Driven Gauge of Casing �, v <br /> Irrigation t 1 Gravel aP ck _'? Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 'Other Other Information <br /> Geophysical Surface Seal Installed B .4 <br /> PUMP INSTALLATION: Contractor + <br /> Type of Pump 3 H.P. <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 LocalyiHealth 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 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 G OUTING D A FINAjU-1 INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE 'SIDF_) __ ._ � <br /> -FOR DEPARTMENT USE-ONLY. <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /02 - 1 "7 <br /> ADDITIONAL COMMENTS: M <br /> PHASE I ROUT NSPECTION PHASE XJAIVNAL INSPECTIO <br /> INSPECTION BY ,, DATE /a /G 77 INSPECTION BY DATE G �� <br /> i. F 14 767Fi ua,r . l_7!. <br /> 6/77 _ 2M <br />