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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: : =1601. E. Hazelton Ave. , Stockton,. Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _-0 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date •Issued�_9 -7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 /> JOB ADDRESS/LOCATION ^� _ CENSUS TRACT <br /> Owner's Name / J Phone4 <br /> �' 6 <br /> Address City .. <br /> Contractor's Name L Ce License # ,j_:?j&dhone <br /> TYPE OF WORK (Check) : NEW WELL. / DEEPEN I_I RECONDITION /_/ DESTRUCTION /_7 ~ V <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 /> r. PROPERTY LINE- 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 °Gauge9:of Casing <br /> Irrigation ` "' -Gravel Pack"' Depth of Grout Seal <br /> Cathodic Protection, Rotary °r� .Type of Grout <br /> ~ + <br /> Disposal �`.. Other _ Other Information <br /> Geophysical 41 Surface: Seal Installed B3 <br /> PUMP INSTALLATION: CRn'tractor <br /> Type of Pump i H.P. <br /> PUMP REPLACEMENT: -4-State Work Done R f � <br /> PUMP REPAIR: T/ f: State Work Done <br /> DESTRUCTION OF WELL: Weli Diameter Approximate Depth <br /> Desgribe Material and Procedure <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 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 /> G information true- to the .bes of. my knowledge and belief. I WILL g4L FOR .'GROUT-INSPECTION <br /> ' PRIOR TO OU NG AND.,„A .,EINE. N <br /> SIGNED i` 12 s TITLE <br /> i ' PLOT PLAN ON REVERSE S111U) <br /> �_j4-70R DEPARTMENT USE ONLY . <br /> PHASE .I f <br /> APPLICATION ACCEPTED BY CO DATE O <br /> ADDITIONAL COMMENTS:.- '- :_ .3 ;:w ,o,i%`, :f i.'b.c: <br /> PHASE I . 0DT-1NSPICTION P S IN INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE <br /> 7.7 <br /> E H 1426 Rev-•x--74 ' <br />