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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 160 . Hazelton Ave. , Stockton, Calms <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.17-37,.1, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7� <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 Lcal Health District. <br /> I 10,C <br /> JOB ADDRESS/LOCATION 172) j CENSUS TRACT <br /> 44/Owner's Name /A_4AZ t_ ' Phone <br /> Address %/p � ��,�-�� J��c�_ ('� City <br /> Contractor's Name "� �" License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /V _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / / V <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ��U SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD S-o CESSPOOL/SEEPAGE PIT OTHER 4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of .Well Casing <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter / / Approximate De th 3d <br /> Describe Material and rocedure <br /> I hereby agree to comply witX all laws anZf regulatiofis 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN INSPECTION. <br /> SIGNED r/ - ✓ TITLE <br /> DRAW PL10T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '_77:;jDATE z 1 <br /> —Zq <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 <br /> 3/76 2M <br />