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E <br /> Eri ' <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. Hazelton Ave- , ,Stockton, Calif. <br /> R.OFPICE USE: <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-� � <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made 3.to1the 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 /> ..s _/aDCENSUS TRACT <br /> JOB ADDRESS/LOCATION r <br /> Phone <br /> Owners Name <br /> - City rlaj <br /> Address 0 <br /> [[ ` Phone` <br /> Contractor's Name iAA <br /> License �� 33 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other / / <br /> E <br /> / SEWER LINE f <br /> f DISTANCE TO NEAREST: SEPTIC TANX<'3; r7PPIT PRIVY <br /> SEWAGE�DISPOSAL FIELD ESSPOOL/SEEPAGE PIT DOMESTIC WELL <br /> PROPERTY LINEzp PRIVATE DOMESTIC WEL PUBLIC DOME <br /> INTENDED USE. TYPE 'OF_WELL CONSTRUCTION SPECIFICATIONS <br /> f t <br /> Industrial ��a Cable_ Tool Dia. of Well Excavation u <br /> ° Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> i Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection Rotary Type of Grout <br /> t <br /> Other;,.>- Other Information <br /> Disposal 's <br /> Geophysical Surface Seal. Installed By-: <br /> E <br /> r - ,.� f <br /> 1 P"&T INSTALLATION: Contractori-- <br /> Type V hof Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> s PUMP .REPAIR• /'"�t State Work Done <br /> 69&Q 9N 1jP&&-- -ry Approximate Depth <br /> F DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia-�•at d-Procedifre <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 FIFTEEN DAYS <br /> after completion of my workj on a new well, I will furnish the San Joaquin^Local Health District a <br /> i, WELL DRILLERS REPORT of thewell and notify them before putting- the- inuse,` The above, <br /> inform4tiop.4s true to the ' t f" m ;eN. <br /> owledge and belief. I WILL CALL FOR"A GROUT INSPECTION <br /> %PRIOR T R TING AFI P _ :� <br /> TITLE <br /> SIGNED �`-, � -�i <br /> (DRAW PLOT PLAN ON REVERSE SIv` <br /> FOR DEPARTMENT USE ONLY ,• r,�, .'j `` <br /> i. <br /> PHASE I DATE_�' � �;��. <br /> APPLICATION.'ACCEPTED.-BY.- - -- <br /> ADDITIONAL COMkENTS: pHp,gE /FIN INSPECTI <br /> P I!- OUT: NSPECTI INSPECTION BY E,/6 ` <br /> INSPECTION BY r DATE <br /> 1-7.7 2M <br /> ¢ w �• Y IAL T___ <br /> 1-7A Pg/-, <br />