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qtr s t <br /> ,� ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFs;OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7jp'_/7J)0 <br /> TkJ PERMIT EXPIRES L YEAR FROM DATE 'ISSUED Date Issued 3- _—76 j <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 an& the Rules and Regulations of the San ,Joaquin Local Health District. <br /> g �� I <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Ph one '.3 6 cl—3 Y-,f � <br /> Addresscit <br /> j O d r i <br /> y , <br /> Contractor's Name 1__D 4Z& License #T4-) . jPhone3 2j <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN -/? RECONDITION -f-71 <br /> DESTRUCTION /_7 <br /> INSTALLATION j / PUMP REPAIR-/ PUMP REPLACEMENT <br /> Other / / E <br />,DISTANCE TO NEAREST: SEPTIC TANKI /oa l SEWER LINES jam ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /Say CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY LINE .- PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL r )CONSTRUCTION SPECIFICATIONS <br />_. <br /> . Industrial }Cable Tool Dia. of life 11 Excavation q <br /> Domestic/private ;i Drilled ,Dia.- oflWell Casing <br /> Domestic%public.._ . „ =; .�. : Driven--. �.���:�Gaugewo�,,casing <br /> Irrigation ['Gravel Pack Depth of, Grout Seal <br /> Cathodic Protection }Rotary I-Type'of Grout <br /> Disposal 19ther.. Othe Ii%farmation t <br /> Geophysical Surface deal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of, Pump !. H P. f <br /> PUMP REPLACEMENT: , State_V rk done� <br /> PUMP '.REPAIR• y. State Work Done. <br /> - <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 Hdalth 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 /> information.is true to the•best .o£ my.,knowledge and belief. I WILL CALL FOR A GRO�g INSPECTION <br /> PRIOR TO GROUTA 4ED A, INSPEcTIRE. q" : <br /> SIGNED TITLE -1 2 <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 312,3 �� <br /> ADDITIONAL COMMENTS: '-A <br /> PHASE II GROUT -INSPECTION PHA NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H '1426 Rev. 1-74 r L175 2M <br />