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Y r <br /> f r ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0fi OFFICE-'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Peftit No. -7.7 y00 <br /> � <br /> ? THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> /1_�,, 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct " . <br /> and/or install the work hererin described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 aiid the Rules and Regulations of the San Joaquin Local Health District`. <br /> .TOB ADDRESS/LOCAT N } a. .-Le CENSUS TRACT <br /> Owner's Name Phone <br /> # r <br /> Address City .. '..- <br /> Contractor's Name "zSt <br /> License #-I&O e4 Phone " <br /> r. <br /> TYPE OF WORK (Check): NEW WELL'/? DEEPEN /� RECONDITION / DESTRUCTION / . <br /> PUMP INSTALLATION / / PUMP REPAIR"/ / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST'-./, 'SEPTIC TANK SEWER LINES PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> - PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEJL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . .. <br /> Industrial ` Cable Tool Dia. of Well. Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> --Domestic/public Driven-- ---Gauge...of. -r-�- <br /> Irrigation .. Gravel Pack V'•"Depth,of GGr6`u&-4ea1 <br /> Cathodic Protection " "Rotary - Type ofGrout - <br /> Disposal Other ` Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor S&gQ5� +� <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State\Work Done <br /> PUMP .REPAIR: / / $State Work Done -f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Y 4 <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 FIBTBw lYS <br /> after completion 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 att+ove- ; <br /> information is .true to the-best of my knowledge and belief. I WILL CALL R A GROUT &SFECTIUI+1;" <br /> PRIOR TO GR TING ANI),"INA,11 INSPE ON: . -' <br /> SIGNED TITLE <br /> 'RAW PLAN 'ON REVERSE SIDE ;1. , <br /> ! R DEPART T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY n DATE <br /> ADDITIONAL COMMENTS: i `• - <br /> PHASE II GROUT. NSPECTION PHASE,,V1 F INSPECTI <br /> INSPECTION BY ' DATL INSPECTION BY DATE <br /> V76 M : <br /> E H 1426 .Rev. 1-74 ,c a <br />