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} <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I� Telephone: (209) 466--6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> VV <br /> ` r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /yam <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 /> ff ' <br /> JOB ADDRESS/LOCATION 0 s'� .� CENSUS TRACT j <br /> �. I I <br /> Owner's Name �� - Phone <br /> I <br /> Address , <br /> City <br /> Contractor's Name �' cense a AL Phone <br /> TYPE OF WORK (Check) : NEW WELL /° 9 DEEPEN /. RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP �INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC �_—TANK �_S 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 k "t`' Cable Tool Dia, of Well Excavation <br /> fes'Domestic/private !1' = '" Drilled Dia. of Well Casing _ <br /> Domestic/public ! !I . Driven Gauge of Casing J J� <br /> Irrigation ' Gravel Pack Depth of Grout Sea <br /> Cathodic Protection t '� s�- Notary Type of Grout <br /> Disposal I` -=Otkiez,:f x Other Information <br /> GeophysicalSurface Sea <br /> l Installed By-2� 2- <br /> � <br /> ,. <br /> PUMP INSTALLATION: Cont actor • <br /> Typeof PumpH.P. <br /> _ L <br /> PUMP REPLACEMENT: /. / State'Work Done <br /> PUMP .REPAIR: / J .;State Work Done <br />' DES•TRUCTION OF WELL: =Wel1 Diameter ""3 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 wor 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 thW est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOGR I ANDA FIN A3 INSPECT <br /> SIGNED .-2 TITLE 45;9M - -- -- - <br /> iM (DRAW PLOT PLAN ON REVERSE SIDE) <br />' FOR AWTMENT USE ONLY <br /> PHASE I Ip <br /> I APPLICATION ACGEPTED BY ? F DATE 1 Q <br /> ADDITIONAL COMMENTS: p <br /> PHASE II GROUT11INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE '"n INSPECTION Y-,( DATE7-73 <br /> /77- _ 2M <br /> E H 1426 Rev. - I-74 _ �`�. <br />