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aq / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FOfx;OFFICE USE: VVV 1 <br /> 601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �/ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE '( 76 -394 <br /> SSUED Date Issued -, <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 herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> f JOB ADDRESS/LOCATION ®11 deo 3 CENSUS TRACT <br /> Owners Name a Phone ,;7 <br /> Address i City- <br /> Contractor's Name <br /> 3A <br /> License # 'q <br /> JPh one �(�S <br /> TYPE OF WORK (Check) : NEW WELL f DEEPRECONDITION 17 DESTRUCTION /_ <br /> PUMP�INSTA- LL ION 'J UMP PAIR/� PUMP RF.gLACEMENT <br /> Other / // r/d/f 'NOF <br /> '077 <br /> DISTANCE TO NEAREST: SEPTIC T K /Qd 1 5 EWERv LINES Z40 PIT PRIVY <br /> tnv 0-- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL_ " =PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing -' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ 1 <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed B : w <br /> PUMP INSTALLATION: Contactor r. U <br /> k Type of Pump v v r <br /> H.P. T <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP '.REPAIR: _..__�"'= ' �-_';;.:�„`;:.`_ �'• <br /> / J State Work Done <br /> , DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws--an-d-- regulations of the San Joaquin Local Health District "- <br /> and the State of California''pertaining to or regulating well ''construction. . Within FIFTEEN DAYS \W <br /> after completion of my work on a new well, I will furnish the San ,Joaquin Local Health District <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 F R-A -GROUT INSPECTION <br /> PRIOR TO GRO TING MD A /FINAL I SPE N;- <br /> SIGNEDa 4A TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHFOR DEPARTMENT USE ONLY <br /> PHASE I. _ <br /> APPLICATION ACCEPTED BY 1 DATE /76 <br /> IADDITIONAL COMMENTS: <br /> PHASE II GROUT `INSPECTIQ tv-xv cu PHASE IAL YNSPECTIO <br /> INSPECTION BY ��10 �. DATE IFSPECTION BY DATE <br /> E H 1426 �V"" c ? <br /> ," Rev. 1-74 "�fi y �. r r ��R <br />