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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH U2FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (2099 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedMAR 14 1978, <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 <br /> aathe <br /> � Rules jand Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION �it- Q� �!� t ��GL� � CENSUS TRACT <br /> Owner's Name L9 Ir Phone <br /> Address r[ � � �2 City <br /> Contractor's Name License <br /> n <br /> a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ' <br /> Other <br />, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 4----Cable Tool Dia. of Well Excavation <br /> f� <br /> Dome stic/privateDrilled. Dia, of Well CasingCC <br /> Domestic/public Driven Gauge of Casing �. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> C — <br /> afhodic Protection Rotary Type of Grout <br /> ti <br /> #t <br /> Disposal Other Other Information <br /> Geophysical <br /> r_ Surface Seal Installed B <br />` PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />` PUMP REPLACEMENT: r <br /> State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure y <br /> I hereby agree to comply with all laws and regulations ofthe San Joaquin Local Health District <br /> and the State of California pertaining to or regulating we ll 'constructi.on. 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 beli6f. I -WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROUTING AND A FINAL TNSECTION. <br /> SIGNED <br /> TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY;. <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ -- v � <br /> P SE Z1 OUT INSPECTI P E I I/ NAL INSPEC ON <br /> INSPECTION BY DATE , �' INSPF,CTfON BY DAT <br /> E H 1426 Rev. - i-74 v,�7�7 2M <br />