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f . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton 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 ISSUER Date Issued 7-.aa_?]` <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 Rulesnd e ulat" ns f the San Joaquin L al Health District. <br /> JOB ADDRESS/LOCA (_1 � p` CENSUS TRAC <br /> Owner's Name Phone <br /> i <br /> Address <br /> p. t <br /> Contractor's Name License # ate' \O3 Phone <br /> _ Z <br /> TYPE OF WORK (Check) ; NEW WELL/�EEPEN / CONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /� PUMP REPAIR/ / PUMP REPLACEMENT /7 } <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANKEWER LTN Q -PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ff.�-CESSPOOL/SEEPAGE PIT ---OTHER ---�-. <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In trial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation GKavel Pack Depth of GroutS <br /> Cathodic Protection ;Rotary = Type of. Grout's <br /> Disposal-., Other, < Other Informat n o <br /> Geophysical` - - v . _ Surface Seal Installed B <br /> PUMP INSTALLATION:_ Contractor <br /> / Type of,Pump 14 H,.-P-. , <br /> a <br /> PUMP '.REPLACEMENT: / / State Work Done ' " "` ` <br /> PUMPriREPA <br /> R:-.r -State Work Done <br /> DESTRUCTION OF WELL: Well Diameter t � Approximate Depth <br /> Describe Material and"Rrocedu 1e ` <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 orregulating well'construction. Within FIFTEEN DAYS <br /> after- completion of my work on a new#well, I wi11 furn'fsh-fhe San Joaquin Local Health District k <br /> WELL 11,RILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> informaion is true to e b my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND FI S 0 ;� <br /> SIGNED -1 , _ +TITLE <br /> !,tDRAW PLT PLAN ON REVERSE SIDE) I. <br /> T FOR DEPARTMENT USE ONLY <br /> 1' — r <br /> APPLICATION ACCEPTED BY /91 DATE <br /> � ,_ ; <br /> ADDITIONAL COMMENTS: - <br /> PHASE G I ECTION--�._ y x P ITA/FINAL INSPF T ON <br /> INSPECTION BY DTE Z �t7 r INSPECTION• BY DATE <br /> E H 1426 Rev. 1-744, � `�"` 0�/k., , GV.S 3/76 2M <br />