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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=`6781 q ti <br /> APPLICATION FOR WELL, CONSTRUCTION `OR PUMP PERMIT Permit Nos e <br /> �.� <br /> THIS-PERMIT EXPIRES 1 YEAR FROM DATE :ISSUED Date Issued-/0-3-77 j <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 /> I <br /> JOB ADDRESS/LOCATION S� �} S CENSUS TRACT _--- <br /> 6 74 <br /> Owner's NameU Phone 3 <br /> Address *'' RS ( ��5� City. L �N a <br /> (} <br /> OUL <br /> Contractor's Name 64alPHFIUT- <br /> )DW <br /> ` License.,# CQ�VPhone <br /> TYPE OF WORK-(Che.ck)-:.. .NEW-WELL /_ ..DEEPEN._/ /__RECONDITION /fix/.-:..-DES TRUGTION_/ - - <br /> PUMP ;;INSTALATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 ` <br /> s Other <br />` DISTANCE TO- NEAREST: SEPTIC TANK 1061 SEWER LINES fO0 '- 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. 7of Well Excavation <br />;Domestic:/private Drilled, Dia`. of Well Casing <br /> Domestic/public Driven �: � A; Game; of Casing W <br /> i Irrigationravel. Pack Depth of Grout Seal C3 <br /> Cathodic Protection rotary Type of Grout <br /> f Disposal Other Other Information <br />'F Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type, of Pump H.P. <br /> k ' <br /> PUMP REPLACEMENT: / / State Work Done =` <br /> PUMP .REPAIR: / / Statel,Work,fDone <br /> DESTRUCTION OF WELL: Well'-Diameter � 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 regul-at-ing well construction. Within FIFTEEN DAYS <br />! after completion-of iny3worklon_a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thewell d notify them before putting, the well in use.. . The above <br /> informatioflis true to the est of. my,knowled-ge--and belief. I"`WILL L FOR A GROUT INSPECTION <br /> PRIOR TO GR4TTING AN A KV41i I PECTION. 4 �. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION 'ACCEPTED"BY DATE da37 <br /> 7 <br /> e. <br /> ADDITIONAL COMMENTS: <br /> S I OUT INSPECTION � ` t PHASE II INAL INSPECTION <br /> INSPECTION BY ' DATE' 7 ' 'INSPECTION By <br /> �vh� DATE <br /> € 6/77 _ 2M <br /> E H 1426 Rev. , -74 1 _ <br />