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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO = OFF`i6E-1—USE.,-' 1601 E. Hazelton Ave. , Stockton, Calif. L Q 227 <br /> Telephone: (209) 466-6781 G✓ y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.TA V O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Ym -�� <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 Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION p �2 Z CENSUS TRACT . <br /> Owner's Name ^� �.Q �rQ�� J Phone <br /> I` Address City <br /> Contractor's Name, �� f �, License # Phone S2 3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION / 7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other /-7 <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 SPECIFIC TIONS <br /> Industrial Cable Tool Dia. of Well Excavation ,/ <br /> P---Domestic/private ' Drilled ia hof-Well Casing <br /> Domestic/public Driven Gauge of Casing\ <br /> Irrigation Gravel Pack Depth-of Grout Seal _ <6 A <br /> f Cathodic Protection 0tary Type of Grout <br /> Disposal Other Other Inform atian <br /> If Geophysical Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ? <br /> PUMP REPLACEMENT: �/ / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Pro`cedffre-- -- y <br /> 4 <br /> 1 <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.I. Wittin FIFTEEN DAYS <br /> after completion of my work an a new well, I will furnish the San Joaqu oval Mealth District a <br /> WELL DRILLERS REPORT of the well and notify them-before putting the 1 in use.%.V a above <br /> information i true to the.best f my knowledge and belief. I WILL L FO A GRO SPECT ON <br /> PRIOR TO GR NG AND A FINAL PECTION. <br /> SIGNED TITLE <br /> DRAW-PL-OT PLAN 'ON REVERSE SIDE)zz <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATES ' <br /> ADDITIONAL COMMENTS: -' <br /> PHASE .II-GROUT INSPECT-ION :� `� r PHASE.- II/Ii- NAL INSPEC ION <br /> INSPECTION BY r DATE INSPECTION BY DATE <br /> Nid <br /> 3/76 2M <br /> E H 1426 Rev. 1-- 4 <br />