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� JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFc OFFICE USE: 1601• -. . Hazelton Ave. , Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7,4 LZg p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g-a � <br /> ' (Complete In Triplicate) , <br /> plication 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 Joaquil <br /> 'Aunty Ordinance No. 1862 and the.Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> rl�.er s NameIz�t,¢.•v� &0t r/u-t Phone <br /> dress 3 LEO-- ` ' / City <br /> contractor's Name �J . License #/4!> 2373 Phone3� <br />+ ",YPE' OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR ,54' PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: :.SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> j ! PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL G <br /> INTENDED USE TY�E OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publiDriven l Gauge of Casing <br /> Irrigation ,•. Gravel Packr Depth of Grout Seal <br /> Cathodic Protection ; ` Rotary Type of Grout <br /> Disposals ', �. — Other ' Other Information ' <br /> t Geophysics% Surface Seal Installed Ry_:__ <br /> E <br /> f. ITMP INSTALLATION: Contrac "or <br /> i T e of, Pum `- -�--,L:t•. _ <br /> H.P. <br /> .. O Q <br /> UMP REPLACEMENT: / / State Work Done r <br /> UMP .REPAIR: {State Work Done <br /> GS-TRUCTION OF WELL: Well Diameter. i,`K• _ Approximate Depth <br /> i Describe Material and Prock:Aure <br /> Fi <br /> 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 /> fter completion of my work on a new well, I will-furnish the San Joaquin Local Health District f <br /> TELL DRILLERS REPORT of the well and notify them ;bgfore putting the well in use. The above <br /> information is ue to the best of my knowledge and-belief. I WILL CALL FOR A GROUT INSPECTION <br /> rA.RIOR TO GROUT AND A FINAL SPECTIO <br /> IGNED •mob TITLE <br /> ' ; DRAW -PT5T PLAN ON REVERSE SIDE) t.'i, <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> } <br /> F'aPLICATION <br /> HASE I ACCEPTED BY DATE �6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /6 <br /> ' 3/76 2M <br />