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�•-- b <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �77-d-S 94� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete In Triplicate) <br /> Application i6 hereby made to the San Joaquin Local Health District fora 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/LOCATION 4 O Z. 3 CENSUS TRACT <br /> t _ <br /> .Owner s Name Phone <br /> Address a.� 0 City <br /> Contractor's Name _ License 's 0_9 Phone (J,l `!� <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN -/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> . � Other <br /> DISTANCE TO NEAREST: . SEPTIC TANK 7 S ' SEWER LINES PIT PRIVY <br /> -,SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERCA. <br /> PROPERTY--LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> } INTENDED USE : TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial M. Gable Tool Dia. of Well Excavation b` <br /> Domestic/p`r'ivate - Drilled Dia. of Well Casing _ U <br /> Domestic/public . Driven Gauge of Casing <br /> Irrigation ~"" ` <br /> g . �Gravel Pack ,,,Depth 'of `Grout Seal <br /> Cathodic Protection Rotary Type 'of_Grout <br /> Disposal " Other Other _Information <br /> Geophysical {� 'Surface•.Seal' lnstalled By: <br /> PUMP INSTALLATION: i Contractorf <br /> ' -Type of Pump H.P. <br /> i• fk ' <br /> PUMP REPLACEMENT: <br /> Ll State Work Done <br /> PUMP :REPAIR: L7 State Work Done <br /> j j2ES TRUCTION OF_WELL.: Nell-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. 'LWithin 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 putting.the-.well in.use.. The above - . <br /> information is true to the-best-of my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING ANDtA F NAL INSPECTION. <br /> SIGNED ( ---- TITLE <br /> _ DRAW--PLOT -PLAN-ON- REVERSE-SIDE <br /> FOR DEPARTMENT .USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS. INSPECTION PHA 1 INAL INSPEGTIO <br /> INSPECTION BYftv. 4 <br /> DATE INSPECTION BY ,�.- DATE ?7 <br /> jA <br /> E H 1426 } v � xc .r � '` t lP �d -7G 2M <br />