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SAN JOAQUIN LOCAL HEALTH DISTRICT ~ <br /> FOS;'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED77°L#S/0 <br /> (complete In Triplicate) Date Issued,Z�J <br /> Application is hereby made to the Sun 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 Joaquin <br /> County Ordinance No. 1862 a d the Rules and Regulations of the Sa Joaquin Local Health District. <br /> 35'05'6 .S- 9r2l- k <br /> JOB ADDRESS/LOCATION / f �. '-T�7 0-c)J <br /> CENSUS TRACT <br /> Owner's Name •} �} y� a Yv 0. <br /> Phone - <br /> Address <br /> hone Address (30 Ljpe <br /> 414 City j c n <br /> Contractor's Name f1 tt� M <br /> License 7G:i Phoned 7 <br /> TYPE OF WORK (Check): NEW WELL -//y( DEEPEN ,/_7 RECONDITION /_7 DESTRUCTION <br /> PUMP INST-ALEATION �f PUMP REPAIR /� PUMP REPLACEMENT/� (;it <br /> Other /% k -- <br /> DISTANCE TQ NEAREST: SEPTIC TANK . I <br /> . SEWER LINES # PIT PRIVY � <br /> SEWAGE DISPO ,FlEtD ` � CESSPOOL/SEEPAGE PIT { <br /> PRQPERTY LIN PRIVATE DOMESTIC WELL PUBLIC DOMESTICTWELI, Cn <br /> INTENDED USE TY?E OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation <br /> TECIFICATIONS <br /> Domestic/private _ Drilled Dia. of Well Casing /f <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of- Grout Seal <br /> Cathodic Protections Rotary Type of Grout <br /> Disposal _ Other Other Information , <br /> Geophysical Surface Seal Installed E <br /> PUMP INSTALLATION: Contractor ' t <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: L/ State Work Dane <br /> PUMPIREPAIR: /-7 State Work Done <br />)ES'TRUCTTON OF WELL: Well Diameter <br /> Describe Materialand Procedure Approximate Depth <br /> . . . . . . . J <br /> C hereby agree to comply with ala laws and regulations of the San Joaquin Local Health District <br /> Ind 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 /> TELL DRILLERS RE RT of the well and notify them before <br /> ore putting..the..well- in.use.,.. The above <br /> r e to the,best -of. my.knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> RIOR TO I IVAND A FINAL INSPECTION. <br />'IGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE — -- <br /> HASE I F10_RDEPARTMENT USE ONLY <br /> PP~ LICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE •/ yc. � .- . <br /> PHASE II GROUT INSPECTION. � <br /> 96ECTION BYPHASE III FIN I PECTION <br /> DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />