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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> -TO-F,-"OFFICE USE: 1601 E. Hazelton Ave v, Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATI N F R WELL CONSTRUCTION OR PUMP PERMIT Permit No. - <br /> S I Ar OiC n-- <br /> THIS P RMIT EXPRES 1 YEAR FROM DATE ISSUED Date Issued <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/LOCAT N CENSUS TRAC <br /> Owner's Name Phone �� —S'6 <br /> Address (�S~ Cit <br /> LO, c"j C� <br /> .. <br /> Contractor's Name License iL3 /Phone94 4 <br /> �Q3�] <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ RECONDITTQN /-7 DESTRUCTION <br /> PUMP INSTALLATION/ UMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PPT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation // <br /> if <br /> Domestic/private Drilled _ Dia. of Well Casing 6 ! _.T a <br /> Domestic/public Gauge,of 'Casing- <br /> Irrigation <br /> Casing!Irrigation Gravel Pack Depth of Grout Sea �O <br /> Cathodic Protection Mary Type of Grout os1 <br /> Disposal Other Other Information 8 ' <br /> Geophysical ;� _ face Seal Insta--;Ty:, B / 6 <br /> PUMP INSTALLATION: Contractor <br /> Type of P H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: . , / / State Work Done <br /> ' � � ' -� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> p <br /> Describe Material and Procedure <br /> I hereby agree toecomply 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 /> WEL DRILLERS REPORT of the well and notify them before putting the well in ruse-.---The-.above <br /> info tion is true toMFI %P�EW- <br /> SIGNED <br /> knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GROUTING AN 1 k, TITLE., <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTbqNT USE ONLY <br /> APPLICATION ACCEPTED BY -a-4- DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION 'PHASE-I /FIN L INSPECTI N 8 <br /> INSPECTION BYDATE p INSPECTION BY DATE / <br /> / 3/76 2M <br /> E H 1426 Rev. 1-74/51 <br />