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t - Yom`✓: <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR x�FFC�,_,USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. Q <br /> Telephone: (209) 466-6781 <br /> 14 11cl APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �_, --.17 V <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to constr---et- <br /> and/or install the work herein described. This application ismadein compliance with Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dist#ct. <br /> JOB ADDRESS/LOCATION LIVE Q� MMAX alaM £jdn Uzi gj S CENSUS TRACT <br /> � s <br /> Owner's Name hone <br /> Address 1 n City n <br /> Contractor's Name 7q� re_ r� ��T��� 'f' License V '��/ Phone yp <br /> S�sL. i <br /> TYPE OF WORK (Check) : NEW WELL J/ DEEPEN/ / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK NBNc SEWER LINES 1V6N£ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /%tC.A&r CESSPOOL/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 <br /> Domestic/private - Drilled Dia. of Well Casing 1!� <br /> Domestic/public Driven Gauge of Casing 4e <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout Nmu <br /> Disposal Other Other Information --jab jay Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump U.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done S <br /> DESTRUCTION OF WELL: Well 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. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a I <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above 1 <br /> information is true- to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION 1 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> y� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> E/� / �y- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS IJ/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> E H 14261-74.R y e , 177�7 <br /> _ __._... --. <br />