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_ 0 SAN JOAQUIN LOCAL HEAL DISTRICT <br /> s. <br /> Fol OFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2 7-3aeu1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (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. 18 i 62 and the Rules and Regulations of the San Joaquin Local Health-District. <br /> b3 <br /> JOB ]]DRESS/ZOCATION CENSUS TRACT <br /> 9°�r �r� , ?/— <br /> Z"97 <br /> Owner's Name 1' � Phone <br /> All- <br /> Address City <br /> Contractor's Name License # Phone ' ' <br /> TYPE OF WORK (Check) : -NEW WELL /�T DEEPEN/ / RECONDITION /_ DESTRUCTION <br /> STUMP INSTALLATION I / PUMP. REPAIR I / PUMP REPLACEMENT 17 <br /> 1Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> P;ROPERTY LINE - PRIMATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 1e TYPE OF WELL CONSTRUCTION SPECIFICATIONS. ( ` <br /> Industrial Cable Tool Dia. of Well Excavation "V <br /> Domestic/private-11 Drilled Dia. of Well Casing <br /> Domestic/public ,I Driven Gauge of Casing \ <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation 0 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal.. _, . Other Other Information <br /> 3 Geophysical Surface Seal Installed By: -- <br /> PUMP <br /> :PUMP INSTALLATION. "Cantractor H.P. <br /> ��Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: ; f / State Work Done <br /> DESTRUCTION OF WELL: IWell.Diameter !� Approximate Depth <br /> ::De tribe Ma erial and Procedure <br /> i' tA� O f <br /> h <br /> I hereby agree to comply witlY all laws and reg 1a ions of the San Joaquin Local ealth Distric <br /> and the State of California pertaining. to or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my�!work on anew 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR"' " ROUTING-AND A FIN - NSPX CT ION: <br /> SIGNE TITLE <br /> D W ' PLAN 'ON REVERSE SILET <br /> a II FOR DEPARTMENT USE ONLY <br /> PHASE Y <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G INSPECTION PHASE III FI AL INSPECTION p <br /> INSPECTION BY " DATE INSPECTION BY DATE <br /> 3/76 <br /> E H 1426 Rev. 1. 74 2d <br />