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4 I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� OFFICnher <br /> USE: <br /> IN 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> °'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> l� THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED <br /> Date Issued <br /> Complete In Triplicate)Applicatioy 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 Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District <br /> t - <br /> JOB ADDRESS/LOCATION �! f . <br /> V CENSUS TRACT <br /> Owner's Name54��1let <br /> Address one 2�Lz 7 <br /> City . <br /> Contractor's Name ' <br /> License # <br /> Phone <br /> TYPE OF WORK (Check): NEW WELL LVDEEPEN '/_T RECONDITION /j DESTRUCTION <br /> PUMP INSTALLATION %/ PUMP REPAIR'/� PUMP REPLACEMENT %f w <br /> Other %// - k <br /> DISTANCE TO NEAREST; SEPTIC TANK ��► <br /> SEWER LINES PIT PRIVY,. <br /> SKWAGE DISPOSAL FIHLD CESSPOOL/SEEPAGE PIT _ <br /> OTHER <br /> FRQPERTY LINE - PRIVATE DOMESTIC WELL­—PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial �. CONSTRUCTION SPECIFICATIONS <br /> Cable Tool <br /> Domestic/private H ` Drilled Dia. of Well Excavation s� � � <br /> Domestic/public i Driven Dia. of Well Casing sf C <br /> Irrigation Gauge of Casing <br /> Cathodic'Protection RotaryY <br /> Gravel Pack Depth of Grout Seal <br /> _ Type of Grout <br /> ._,,,"_,Disposal Y -Other, . . <br /> Geophysical , = Other Information _ <br /> Surface Seal" Instal ~+ <br /> UMP INSTALLATION: A.. Contractor k ' <br /> .—TYpe of Pump H:F. _ <br /> UMP REPLACEMENT: y/ ;`/ State Work Done <br /> 777-. <br /> t M <br /> g' HP 'REPAIR: /7 : State Work Done - <br /> DES4RUCTION OF WE ell Di meter <br /> Z <br /> D # Approximate Depth <br /> C.. f ►: <br /> Des a Mat ria and P ocedu e -----��- <br /> Iher y agree to comply' ith al Taws d regulat£o of th n Joaquin ocal. ea tli Di <br />$nd`the State of Californric <br /> ia pertaining to or regulating well ''construction. Within FIFTEENtDAYS <br /> after compietion. 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 FOR 'A 'GRO <br />%100 TO G OUTING INAL I PE <br /> SIGNED N. UT INSPECTION <br /> TITLE r <br /> D P P ON SE SIDE <br />?RA�_Ip FO EPARTMENT SE ONLY <br /> 00 V <br /> WLICATION' ACCEPTED.BY I r <br /> IDD�F`IONAL COMMENTS: DATE <br /> P GRO INSPECTION P S I FIN INSPECTION <br />[NSeECTION B ATE ` <br /> ;' —7 INSPECTION BY <br /> t E,H 1426 Re <br /> v. 1-74 j <br />