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r <br /> FOS " .a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> *0'_F_F10E US : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 �/Q <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / 4 �y <br /> { THIS PERMIT-EXPIRES i YEAR FROM DATE ISSUED Date Issued" <br /> f (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 Local Health District. <br /> I JOB ADDRESS/LOCATION- / _ CENSUS TRACT ' <br /> Phone <br /> Owner's Name # <br /> Address City <br /> Contractor's Name - t. Y '' License &3j6&;7-5-55 Phone - <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPE / RECONDITION /_/ DESTRUCTION I_r <br /> PUMP INSTALLATION /� PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK=_. . _SEWER-LINES /ol PIT PRIVY <br /> SEWAGEiDISPOSAIt FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F ? ' PROPER`A 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 %Gauge­of"-Casing <br /> Irrigation Gravel Pack "Depth° of Grout Seal <br /> --------------- <br /> Cathodic Protection : Rotary 'Type .of=Grout <br /> j Disposal Other ►:Other Information <br /> h Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r . ' .� f f eel%` V4 t <br /> Type of Pumpell f <br /> 'r ,� H.P. . <br /> k PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> S <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 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 furn sl. the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before "putting. the� ell in use.. The above <br /> information is true to the best of. my knowledge and ,beliei. I WILL 'CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO-UTING AND -A,FT-NAL, INSPECT ION. <br /> " SIGNED �.�� w <br /> �' `��"t. s TITLE <br /> t (DRAW PLOT PLAN 'ON REVERSE SIDE) <br /> FOR DEP MENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY DATE r <br /> 27 <br /> ADDITIONAL COMMENTS: <br /> I PHASE I GROUT INSPECTION PHA IT�F NAL INSPE ON <br /> INSPECTION BY DATE — _711P <br /> INSPECTION BY DATE � <br /> 0/77 _ 2M <br /> V T3 1A7A uo.> I_7L <br />