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Pom SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F OFFI E USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781. ���'� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued19 <br /> 41,02 *k4 S 4 (Complete In Triplicate) zU f- f(0_01� <br /> Application is hereby made to the San Joaquin Local Health'D.istrict 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. 1.862 and the Rules .and Regulations of the San Joaquin Local He lth Dis c <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �a YY f �G�.�f �""' - — — Phone <br /> Address City C fit• <br /> Contractor's Name License # /V-74Phone ; —7426 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION ./ <br /> PUMP INSTALLATION PUMA' REPAIR PUMP REPLACEMENT /_7 � I: <br /> Other _f -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIFE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL €j <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 f <br /> Type of Pump Gc d' H.P. <br /> o <br /> PUMP REPLACEMENT: / / State Work Done _ - <br /> PUMP REPAIR: / / State Work Done _ 4- 4)444 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> -- __ Describe Material. and Procedure <br /> 4 I 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 /> 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 FI AL_ INS CT '0'N <br /> SIGNED TITLE <br /> (I>iAW PLO's PLANCON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE �2 ADDITIONAL COMMENTS: a <br /> PHASE:. OUT INSPECTION 'PHASE III/FINAL INSPECTIODT <br /> INSPECTION BY� -ADATE ---INSPECTION BY G��f' DATE fe 7 7,F� <br /> 6/77 _ ;2M <br />