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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F.O�: OFFICE USE: - 1601 E. Haz&toi 4Xve. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 �� .. .� <br /> APPLICATION FOR WELL CONSTRUCTION OR A <br /> PUMP PERMIT Permit No. /0 <br /> 1 --- --r— <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" Date Issued l42 <br /> (Complete In Triplicate) <br /> Application' is 'Aereby' made to the San 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 Or i ance.jTo. -1162 e R s and Regulations of the San Joaquin Local Health DistiricC. <br /> JOB ADD <br /> DGATIQN, -140C-e- CENSUS TRACT <br /> Owner's Name � �-d�tl� Phone <br /> Address 42 . C <br /> Contractor's Name ticensel / �� � <br /> ,3Phone <br /> TYPE OF WORK (Check) : NEW WELLI/ , DEEPEN / / RECONDITION /7 DESTRUCTIONS <br /> PUMP INSTALLATION / / PUMP.- REPAIR /, / PUMP REPLACEMENT f_�. { <br /> Other / / - s 1 . <br /> DISTANCE TO NEAREST; SEPTIC TANK .SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Com` <br /> s PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL-�� <br /> INTENDED USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Taal Dia, of Well Excavation <br /> e/ <br /> Domestic/private_ Drilled* bia. 'of Well Casing <br /> Domestic/public ._ Driven F Gauge of Casing J �J <br /> Irrigation I It!:- Gravel" Pack Depth of Grout Seal D � <br /> Cathodic Protection ✓. Rotary i` Type of Grout. '. <br /> Disposal ; Other I Other- Information <br /> Geophysical ` Surface Seal Installed B <br /> PUMP INSTALLATION: / " Contractor <br /> . . Type of Pump H.P. <br /> �j������ � <br /> PUMP REPLACEMENT: / State Work DYet��""` <br /> PUMP .REPAIR: "/ / State Work 'Done. ' <br /> DESTRUCTION 'OF WELL: '� <br /> Well Diameter ir= ' s Approximate Depth f/W� <br /> " Describe'.Miterial and Procedure el <br /> I hereby agreelto comply with an—laws and regulations of the San Jo quip Local Health bistrict <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.,.LocalHealth District: a' <br /> WELL DRILLERS REPORT of the well and notify them before putting tle..well in usek. Ad above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. . <br /> SIGNED TITLE �J <br /> (DRAW PLOT PLAN ON'� REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; T• <br /> APPLICATION ACCEPTED BY Goi1. 4AT�/- 7 , <br /> ADDITIONAL COMMENTS. 0 ,cj p t , �e`717 - <br /> _ <br /> PISA ,II s G OU,TI INSTECTIONPHA II/ NAL INSPECTION <br /> INSPECTION BY DATE �� �7f 78 INSPECTION BY DATE 7 <br /> 1177 <br /> E H ';1426 Rev. 1-74 _ ` <br />