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MI <br /> M, <br /> 1 <br /> f e�a �'.a •' SAN JOAR UIN LOCAL HEALTH DISTRICT <br /> 40B DOFF CE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephones (209) 466-67$15=3 �p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS MET EXPIRES 1 YEARDATB ISStHO? Date Issued Z <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District fora permit to construct <br /> and/or install the work herein described. This application is maids in awliance with Son. Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Son JosquSu Loci, Realth,.91otrict. <br />-JOB ADDRESS/LOCATION r114,P`•Y�«� - �/,� � CBMSUB TRACt <br /> Owner's Namer �n r 7-. r Phone <br /> t h. ., . ____....._ <br /> Address adz= City <br /> Contractor's Name : S License # 1ho" , <br /> r <br /> TYPE OF WORK (Check): NEW WELL,. DEEPEN '/? RECONDITTON f7 DEBT'RUCTION 0 <br /> PUMP INSTALLATION L_7 PUMP REPAIR PUMP REPLACEMENT jg p <br /> Other L? V J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD C$SSPOOL/SWAGE PIY_ OTHER <br /> MWITY LM - PRIVATE MOTIC '._.,_ PUBLIC RMTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC FICATIONS <br /> Industrial Cable Tool Dia. of We11 Excavation <br /> Domestic/Private ' Drilled Dia. of Well Cooing <br /> Domestic/public - Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Great Seal <br /> Cathodic Protection Rotary Type of Groat <br /> Disposal Other Other Information <br /> -Geophysical IT surf Mg seal Installed Bvs <br /> PUMP INSTALLATION= Contractor <br /> Type ,of Pump <br /> PUMP REPLACEMENT: L-? State Work Done <br /> PUMP :REPAIR: d. State Work Daae <br /> 2ES+IjUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mater al and Procedure <br /> I hereby agree to comply withal laws and regulations of the San 36j4i&i Local Bealth District <br /> and the State of California pertaining to or regulating well''c6notruetion. Within, lIFTSBt DAYS. <br /> after completion. of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before put .the..v*ll. 1u.use... .The above <br /> information is true to the best of my;knowledge and,•bief.. L CUL Pa'A'GROUT INSPRCTION <br /> PRIOR TOG INC ANDA F INSPECTIO <br /> Ir . . ,. <br /> SIGNED N!r <br /> RAW P= PXAN ON WME SIDE: <br /> FOR ART10Df'f USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DA /z � <br /> ADDITIONAL -- <br /> COMMIS: <br /> PHASE II' GST INSPECTION ` PHASE III FIUAI. IREPBCTION <br /> INSPECTION BY DATE INSPECTION EY DATR _ r- _ <br /> r J <br /> 2 H' 1416 Rev. 1-74 <br />