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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR7OFFICE USE: 1,1Z 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T 0/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'iSSUED Date Issued 3- 2-5--A <br /> ° .,.y (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install thework 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 /> 19, 's, . 0 A/-I L'.1) P . - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner s Name l J,j ! Phone 72--, <br /> Address - 7,,,1 � ] <br /> City <br /> COL <br /> tractox's .Name i. L ,,o ` License # <br /> _ -,_...,... ,. o�O Phone <br /> TYPE YOF WORK (Check) : <br /> `NE' W WELL -/-7/-7 DEEPEN �/7 RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other ! % /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP05AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USEr TYPE OF WELL I CONSTRUCTION SPECIFICATIONS <br /> Industrial ~Cable Tool Dia. of Well Excavation <br /> _-- Domestic/privAte It; -,') ,Drilled Dia. of Well Casing <br /> Domestic/public Driven. Gau a of Casing <br /> Irrigatioti� Gravel Pack Depth of CasiGroutgSeal, <br /> Cathodic Protection Rotary Type-of"'Grout' ` <br /> Disposal , Other ��` Other Information'' ,. k- <br /> Geophysical _ Surface Seal Tn'stalled B ` <br /> PUMP INSTALLATION: Contractor Is, <br /> Type of Pump _.� �. t H.P. i <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ . <br /> PUMP"'.REPAIR:= <br /> gtaQ00 <br /> tc Work Done - <br /> 4 <br /> ES xRUCTION 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 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 r <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 GRO ING AND A F AL SPECTION, <br /> SIGNED TITLE 3 <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED E <br /> BY DATE � ,2 <br /> ADDITIONAL COMMENTS: � � <br /> --- <br /> PHASE. IT PPE IO <br /> GR N NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1--74 ' <br /> 1--74 2M <br />