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SAN JOAQUIN LOCAL. HEALTH DISTRICT T <br /> -V—OF-,,OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��1�1 <br /> M ,r 77-Id/67� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � 7: <br /> ` (Complete In Triplicate) <br /> Application is 4ereby made tI the San Joaquin Local Health District for a permit to construct <br /> 1 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 /> JOB ADDRESS/LOCATION z 4,10 P-a_wr, CENSUS TRACT <br /> ;1 <br /> Owner's Name Phone <br /> Phone <br /> � Address __ ���-�P� City <br /> Contractor's Name License 4� Phone ' <br /> I TYPE OF WORK (Check) :' NEW WELL DEEPEN/, / RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION h< PUMP.'REPAIR-'/ / PUMP REPLACEMENT /7 <br /> ' Other <br /> DISTANCE TO NEAREST: _ SEPTIC, TANK 60 SEWER LINES i +SPIT PRIVY <br /> SEWAGE DISPOSAL E.I.ELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/y4RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domes�ic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack -Depth of Grout Seal ,Sp <br /> Cathodic Protection Rotary Type of Grout7a <br /> Disposal Other ;'�' Other Information <br /> Geophysical Surface Seal Installed Bv: <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump z j ` F;� ,, . H.P. <br /> PUMP REPLACEMENT: / / EState 'Work Dorie <br /> PUMP REPAIR:.- / / State Work:Done a. <br /> 1}ESTRUCTION OF WELL,: i Well,Diameter Approximate Depth <br /> -Describe Materiai -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 ' 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 t e t of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO GROUTING N, <br /> SIGNED TITLE <br /> ' (DfLAW-PLOT.PLANrON REVERSE-•SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> ' APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P4SF1 I FINAL INSPECTION <br /> , INSPECTION BY DATE Z INSPECTION BY DATE <br /> 1f7724 <br /> E H 1426 Rpv_ 1-7G �� <br />