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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> V. <br /> 'e.7-,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ` <br /> ` LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, -7.35,'!tLl 3 <br /> J { <br /> THIS PERMIT EXPIRES '1 YEAR FROM DATE ISSUED Date Issued i -za.-ZI <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 Local Health District. <br /> JOB ADDRESS/LOCATION.__? �' <br /> . . ' . . .. . � � '* �._,.�� US TRACT <br /> Owner's Name Phone , I <br /> Address City . . <br /> F <br /> f s <br /> ContractoiC's Name License19�{ Phoned <br /> TYPE OF WORK (Check): NEW WELL /-V—DEEPEN /_7 RECONDITION ' DESTRUCTION f-7 <br /> PUMP INSTALLATION "/,A-t 'PUMP REPAIR�f 7F PUMP REPLACEMENT. f7 <br /> Other /% <br /> DISTANCE- TO NEAREST: SEPTIC. TANK SEWER EINES 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 <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 <br /> _ Type of Grout . . 4 Ir fr <br /> Disposal Other . <br /> Other Information. <br /> —Geophysical Surface Seal Installed a I x By <br /> �,. <br /> PUMP INSTALLATION: Contractor r <br /> Type .of Pump H.P. .,. <br /> PUMP REPLACEMENT: . / <br /> State Work Done <br /> PUMP :REPAIR: State-Work Done . <br /> DESTRUCTION OF, WELL: ' Well Diame der' o <br /> �ry 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 completions of 'my work on a new well., I"wil.l furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify thei*,b'efore putting. the,-well. in.use... The above <br /> information is true to the-best.of my-klowledge„and belief.._.I WILL CALL FOR A. GROUT INSPECTION <br /> PRIOR TO GROU iNG;AND A FINAL -INSPECTION,s` ._ <br /> SIGNED ' ° `..:� _ f4�,, TITLE <br /> ' DRAW PLOT PLAN ON REVERSE SIDE .•rs +" r <br /> , FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION A8CEPTED BY DATE <br /> ADDITIONAL 901'PZNTS: <br /> PHASE. II GROUT INSPECTION ".P SE I FIN INSPECTION <br /> INSPECTION BY - DATE-*, • •;:.._ , ]CNSI'EGTION BY DATE <br /> q <br /> E H 1426 ' Rev. 1-74 r 1./oo o,u <br />