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` r <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F09';OFFICE USE: 1601 E. Haztlton` e' . , Stockton , Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J� uJ <br /> THIS PERMIT EXPIRES .1 YEAR .FROM DATE ISSUED Date Issued S�6 <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 descilbed. This application is made in compliance with San 3oaquin <br /> County Ordinance Ido. 1862 and the Rules and Re ulatione of the Joaquin Local Health District.. <br /> JOB ADDRESSAOCATION <br /> CENSUS TRACT - <br /> Owner's Name ., c <br /> Phan - - <br /> Address <br /> han- -Address f , ter- <br /> City- <br /> -Contractor's Name <br /> or License Phone p / <br /> TYPE OF WORK (Check): NEW WELL /!' DEEPEN /_7 RECONDITION _ <br /> /7' DESTRUCTION f7 <br /> PUMP INSTALLATION-/—/ PUMP REPAIR-/-7PUMP REPLACEMENT /7 <br /> ry Other /-7 <br />,DISTANCE TO NEAREST SEPTIC TANK <br /> " SEWER LINES - PIT PRIVY <br /> •{.. � SEWAGE DISPOSAL FIELD CES5POOL/SEEPAGE PIT OTHER 1 <br />•. PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL-�� � <br /> INTENDED US8 TYPE OF WRLL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ✓Domestic/private 4—Drilled <br /> _ Domestic/public "`^"'"" Dia.. of Well Casing � <br /> ,� Driven Gauge of .Casing <br />-__—_ Irrigation Grivel Pack Depth of Grotit :Seal <br /> Cathodic Protection 4-Rotary Type of Grout ' . <br /> Disposal Other ` Other Information " <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION; Contractor 1 <br /> Type of Pump <br />..1t <br /> PUMP REPLACEMENT: e � 1 <br /> // State Work ..Done. <br /> PUMP :REPAIR: <br /> / :State Work Done { <br />)ESjTRUCTION OF WELL: . Well. Diameter <br /> Describe Material and Pcedure Appyoxmate Depth <br /> roi <br /> I hereby agree to comply with. all laws and regulations of the San <br /> Ind the State of California pertaining to or regulating well "construction.Local Withinalth FIFTEENtrict DAYS <br /> after completion of my'work on a new well, I will furnish the San Joaquin Local Health District a <br />?ELL 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 />'RIOR TO GR UTING 'ANDA AL IN ECTIO . <br /> iIGNED ITLE <br /> D PLOT LAN ON REV SE SIDE } <br />'HASE I j FOR DEPARTMENT USE ONLY <br /> SPP IL�CATION• ACCEPTED BYP <br /> ADDITIONAL COMMENTS: D 3 7 <br /> WPIRIA"S I GROG INSPEM PEASE I INAL I PECTION <br /> NSPECTION BY ATIy / INSPECTION BY <br /> Z � <br /> E .$ 1. ' !. <br /> 426 Rev.' 1-74 f . <br />