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31 cr <br /> 4 <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. tazelton Ave. , Stockton, Calif., <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l-LR'_77 E <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 .axid the Rules and Regulations of the San Joaquin Local Health District. <br /> / CENSUS TRACT } <br /> JOB ADDRESS/LOCATION 4 <br /> Owner's Name <br /> Address Q City <br /> If z <br /> Contractor's Name 'n" �� ��Phone== <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INST/ LATION / / PUMP REPAIR / I PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� PIT PRIVY Q/QI <br /> SEWAGE DISPOSALFIELD CESSPOOL/SEEPAGE PIT 8T <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 'Domes pxxvate - Dr3-1-Ted .D a.-of-Well .Cgsin ry <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal Other Other Information <br /> Ceophysi'cal Surface Seal Installed By: <br /> PUMP INSTALLATION.: Contractor _ � _ _.. <br /> Type of Pump V61 H.P. <br /> PUMP REPLACEMENT: / / State Worn-Done <br /> _ <br /> PS�ork Done <br /> PUMP-.REPAIR: _ � -4;7 <br /> DESTRUCT <br /> ION OF WELL: Well Diameter 6)M et �� c e� Approxim.a� Depth � S' <br /> D - c-x.ibe Material and PTpced._r,e�� " .. ' <br /> T hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> E 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 putting the well in use. The above <br /> information 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 : <br /> DRAW 'I: T PLAN 'ON REVERSE SIDE <br />! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA .II 0 INSPECTI PHAS I I IN INSPECTI N <br /> INSPECTION BYIlw_ <br /> X, <br /> DATE INSPECTION BY DAT <br /> ' <br /> � R 2M <br /> E H'1426 Rev. 1-74FV7/ s' <br />