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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> P: OFFICE USE: 1601 E. Haze <br /> lton'Ave. , .Stockton, Calif. <br /> FOrr <br /> { Telephone : - (209) 466-6781 <br /> .y APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> q (Complete In Triplicate) <br /> , struct <br /> o co <br /> Application is `hereby made to ,the San Joaquin Loapl�icatio District <br /> made inrco pliancea permittwithnSan Joaquin <br /> and/or install the work herein described. aP <br /> ' the Rules and- Regulations -of the San Joaquin Local Health Dis.tr ct. <br /> County 'Ordinance No. 1862 and <br /> CENSUS TRACT . <br /> JOB ADDRESS/LOCATION + <br /> Phone <br /> Owner's.Name tG <br /> City <br /> Address • � <br /> I I License_. 0 /l - Phone <br /> Contractor's Name f2 ! z;Ac . <br /> _ DESTRUCTION <br /> - - - - <br /> TYPE OF WORK (Check) : NEW <br /> WELL '/ ION PUMP REPAIR PUMP REPLACEMENT <br /> PUMP INSTALLAT / <br /> Other <br /> SEWER LINES �"` PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK �� r, CESSPOOL/SEEPAGE PIT _ OTHER <br /> SEWAGEIDI5 OSAL�FIELD <br /> PROPERTY LINEW PRIVATE DOMESTIC WELL/WO CONSTRUCTION SPLIC DOECIFICATIONS <br /> YNTENDED USE TYPE OF WELL / <br /> Cable Tool- Dia. of Well Excavation 01 <br /> Industrial Dia, of Well Casing <br /> Domestic/private Drilled <br /> Driven Gauge of Casing <br /> Domestic/public De th of Grout Seal <br /> Irrigation] Gravel Pack P <br /> Te of Grout <br /> Cathodic. Protection Othery � Other Information Or <br /> Disposal <br /> j Surface Seal Installed B <br /> .Geophysical. <br /> Contractor ova �� <br /> PUMP INSTALLATION: H.P. <br /> Type of Pump i3� ry G <br /> PUMP REPLACEMENT: . / + State Work Done <br /> + PUMP -.REPAIR: State-. Work Done <br /> i Approximate Depth _ C <br /> � DES•TRUCTION OF WELL: We11' Diameter <br /> Describe Material and Procedure <br /> Dis <br /> rict <br /> cal <br /> lth <br /> I hereby 'agreeto comply wiIth all law s and regulationh owell'-construction.f the San Joaquin LoWithin aFIFTEEN CDAYS <br /> and the State of California. pertaining t6-;,',or regulate g, <br /> after completion- of my -work on-`a new well,' <br /> Ith�mlbeforesputingathe��rellninouseHeThehabover District a <br /> WELL DRILLERS REPORT of, the well and notify <br /> information is true to the.-�e t o m knowledge and belief:_ I WILL CALL FOR A GROUT INSPECTION <br /> "PRIOR TO ING D A F IN <br /> SIGNED (DRAW PLOT -.PLAN ON REVERSE�SIDE) <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I DATE �IX 7 1 . . <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: pHA III/F�N INSPECTION <br /> PHASE II G OUT INSPECTION '., p INSPECTION BY DATE-3 ! <br /> INSPECTION BY DATE a' <br /> n 1/77 . <br />