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a rr SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE US L' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONST.RUC'TION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I-/" -76 <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _. yy � �vn 7/ A 6 CENSUS TRACT <br /> Owner's Name t,, _0AJ J W _ Phone 9il- 3,-w <br /> Address <br /> 9 9Y � .�� l� city <br /> Contractor's Name _ �ti License # 3 j Phone %�S <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_7 RECONDITION /7 DESTRUCTION /_] <br /> PUMP INSTALLATION /] PUMP REPAIR /-V PUMP REPLACEMENT /_7 <br /> Other <br /> )ISTANCE 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 CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing v <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 1-' <br /> UNP INSTALLATION: Contractor ^� <br /> Type of Pump H.P. r <br /> UNP REPLACEMENT: / / State Work Done <br /> UMP .REPAIR: State Work Done (�j�� . r �, rCL <br /> ?S•TRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd 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 a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> aformation is true to the best of my knowledge and belief. L WILL CALL FOR A GROUT INSPECTION <br /> tIOR TO GROUTING AND A FINAL INSPECTION. <br /> CGNED TITLE 7/� tinrAv✓ <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 1ASE I - <br /> ?PLICATION ACCEPTED BYDATE _j S�, -75— <br /> )DITIONAL COMMENTS: /J <br /> PHASE II I SP TIO_ PHAS IW/FINN;AL INSPECTION <br /> iSPECTION BY DATE INSPECTION BYi� Z~ DATE <br />