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e. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: �6-g3�tJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �,. (Complete In Triplicate) <br /> Application in 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San 'Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION B (� d I �C l CENSUS TRACT <br /> _ mak !! .• '/ q <br /> Owner's Name `J. 2 c• S Phone <br /> Address City ' ' <br /> Contractor's Name 5'P . License U Phone <br /> TYPE OF WORK (Check): INEW WELL, DEEPEN -/7 RECONDITION 1f J DESTRUCTION , <br /> i1PUMP INSTALLATION /% PUMP REPAIR /—] PUMP REPLACEIEN /? <br /> r Other F7 <br /> R <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES • PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC-DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL ,CONSTRUCTION SPECIFICATIONS <br /> Industrial ,; Cable Tool Dia. of ''Well Excavation <br /> Domestic/private , Drilled Dia, of Well-Casing <br /> Domestic/public: ` `4 _ Driven Gauge of Casing <br /> Irrigation ;,. :. Gravel Pack Depth of Grdui Seal -` <br /> Cathodic Protection .'Rotary Type of Grout ' <br /> Disposal ,.. � 0thei, Other Information <br /> Geophysical ,'� 3, Surface Seal Installed 'B <br /> PUMP INSTALLATION: '.'Contractor <br /> :Type of Pump H.P, <br /> t PUMP REPLACEMENT: / / State Work Done <br /> 1 775 , <br /> PUMP '.REPAIR: /7 State Work Done 7 , <br /> DE&TRUCTION OF WELL: . 'Well. Diameter� ._. � A proximate Depth <br /> De cribs Material and Procedure / ram r S <br /> k_ <br /> . a>), t 1,C&nz a-_W . <br /> . 1 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 <br /> WELL DRILLERS .REPORT of the well and notify them before p_ut_ting. the.-well in.use... .The above <br /> information is true to.:the•best ofsmy__knowled-ge 'and_-bel of. I WILL CALF, FORA GROUT INSPECTION <br /> ,PRIOR TO GROUTING_'AND-A-4-VINAL SPECTION. <br /> SIGNEDJkp <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> - - - FOR"DEPARTMENT USE ONLY -•--_-- <br /> PHASE I <br /> APPLICATION ACCEPTED BY c I DATE <br /> ADDITIONAL COMMENTS;: AW / S -7 <br /> PHASE Il GROUT INS CTION HA I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> k. E H 1426 Rev. 1-74 h/75_ -2M <br />