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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave.., Stockton, Calif. <br /> _rte. <br /> Telephone : (209) 466-6781 r 77—Y7 2- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS''PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /S_7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> I' and/or install the work herein described. This application is made in compliance with San Joaquin <br /> k County Ordinance No 1862nthe san �netions o the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '7d6� <br /> CENSUS TRACT � <br /> Owner's Mame F <br /> Phone 3 <br /> Address ( Et <br /> --� City + <br /> Contractor's Name License # a Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION / / DESTRUCTION <br /> PUMP :INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other-r/. / -- <br /> DISTANCE TO NEAREST; SEPTIC.: TANK d0' SEWER LINES PIT PRIVY <br /> SEWAGE--DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o . <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 =_-4 --- Drilled Dia. of Well Casing it / Ltyq <br /> -.-domestic/public _ P �YDriven. -__ G-6u-g—u—f iii � fi � . .4-� .i <br /> Irrigation 'GrAve1"Palk_ __._..De t of"Grout S-eA1 <br /> Cathodic Protection _ Tyg.e_0.fGr_out ,,� <br /> Disposal OtherWrc � Other= information r <br /> r <br /> Geophysical ~. ,Surface5ea1 Installed By-: <br /> Pu <br /> INSTALLATION: Contractor f „/ ;k <br /> Type of Pump <br /> P L REPLACEMENT: State Work Done r " <br /> f <br /> PUMP '.REPAIR: ". / / State Work Done e, A2 <br /> / f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth S <br /> Describe <br /> -Material <br /> and Pro edure <br /> I hereby agree to comply with alljlaws 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 /> WELL DRILLERS "REPORT of the well and notify them before puttingthe well in use. The above <br />.infoi+mation is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - TITLE ,;I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> }� DATE -18 77_ <br /> ADDITIONAL COMMENTS: I <br /> P I QU INSPECTION PHAS III N INSPECTION <br /> INSPECTION BY DATE 7 INSPECTION BY DATE ' <br /> 5-.91 I <br /> E H 1426 Rev. 1-74 176 6c)(f _ _ � �'-1/17 2M 1 <br />