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SAN JOAQUIN LOCAL-HEALTH DISTRICT � <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 t� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ? <br /> 7 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> (Complete In Triplicate) <br /> Application is hereby- made to the San Joaquin Local Hi alth 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 /> JOB ADDRESS/LOCATIONi / i�r//t �� n . CENSUS TRACT _ <br /> Owner's Name c� Phone �b <br /> Address =� r A dA City <br /> C <br /> ontractor,'s Name License dl PE_P - <br /> TYPE OF WORK (Check) NEW WELL �EEPEN /? RECONDITION /7t DESTRUCTION <br /> f PUMP INSTALLATION / / PUMP REPAIR RE''PLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> Industrial ," Cable Tool Dia. of Well Excavation �Q <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> k Cathodic Protection Rotary Ther Ie of nformation <br /> F Disposal _ Others. , w , � .�. <br /> Geophysical. �� Surface Seal _Installed BY: <br /> Net <br /> i r L <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �'� H.P. <br /> PUMP REPLACEMENT; / State Work Done <br /> PUMP :REPAIR: /_7 State Work Done i � -• <br /> ,RE5•TRUCTION OF WELL: Well-Diameter ` Approxiinatey�Depth ��.t.�N <br /> Describe Material and Procedure I 4' <br /> i 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,regulat.ii19-welf construction. Within FIFTEEN DAYS <br /> after completion of my work on a new weftXi,('Iiii .furnish the San 3oaquin Local. Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puit`ing. the. well in.use.. The above <br /> information is true to the-best o . my knowledge and belief_. II,WILL CALL FOR:`*'GROUT' INSPECTION <br /> j PRIOR TO UTIN A FI AL INSPECTION. <br /> SIGNED TITLE . <br /> DRAW PLOT PLAN ON REVERSE'SIDE <br /> 2 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . IQ ! DATE 3 7 S <br /> ADDITIONAL COMMENTS: h1171niek Ind:3 <br /> PHASE If GROUT INSPECTION r PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1~E H 1426 Rev: 1-74 - 1-74 2M <br />