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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. 7 7 11 77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regula * f the San Joaquin Local Health- District. <br /> `� l/� <br /> JUB ADDRESS/LOCATION �,e�-cz CENSUS TRACT <br /> Owner's Name Phonej.12—�� <br /> Address 7 a �i t City <br /> Contractor's Name License ��f(o Phone <br /> i <br /> k TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION J� <br /> PUMP INSTALLATION J / PUMP REPAIR , PUMP REPLACEMENT J� <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 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial # Cable Tool Dia. of Well Excavation p <br /> f i Domestic/private Drilled Dia. of Well Casing <br /> -Domestic/public Driven fir Gauge of Casing <br /> Irrigation Gravel-Pack Depth of Grout Seal <br /> Cathodic Protection Rotary '.f Type of Grout <br /> Disposal Other Other Information <br /> Geophysical J Surface Sea Installed By: <br /> PUMP .INSTALLATION: Contractor <br /> Type of Pump H.P. ? �� <br /> PUMP.-REP-LACEMEN.T_: Work.Done <br />� ,� c <br /> PUMP .REPAIR: !,SCI 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 and regulations of the San Joaquin Local Health District <br /> and the State -of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS F <br /> I 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 puttirig1the well in use. The above <br /> information is true to the best of my owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUVIDG Aj A INSPECT N. <br /> SIGNED TITLE <br /> -- ;-----rsrs. <br /> W <br /> PLOT T PLAN 'ON RE RSE -SIDE) <br /> FOR DEPARTMENT USE ONLY- <br /> PHASE <br /> NLY--PHASE I J �J <br /> APPLICATION ACCEPTED BY DATE <br /> k ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT 0 ' :.. PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA;E 6 +� <br /> TFC ei �j 6 2 <br /> E H 1426 Rev. -1-74 T <br />