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SAN JOAQUIN LOCAL HEALTH DISTRICT ����� <br /> MIT USE: 1601 E. Hazelton Ave. , Stockton, Calif. d <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]�41 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9 g <br /> (Complete In Triplicate) <br /> AppXication 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 AOCATION r b ,� CENSUS TRACT <br /> Owner's Name X` Y_a ` A Phone ,,��.2 � <br /> k Address iii -e - City ' � CC <br /> Contractor's Name4- .-511r-L .�. License # Phone <br /> �- <br /> - <br /> TYPE OFAWORK (Check) NEW WELL/7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION / . <br /> 4�. PUMP-11VSTALLATION / / .PUMP REPAIR / / PUMP REPLACEMENT <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' ' m PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL E �, CONSTRUCTION'SPECIFICATIONS <br /> Industrial Cable Tool Dia. of-Well Excavation- <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Gasing . <br /> Irrigation - Gravel Pack Depth of Grout Seal <br />` Cathodic Protection t Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. - Surface Seal Installed By., <br /> PUMP INSTALLATION: Contractor <br /> Type of .Pump H.P. <br /> PUMP REPLACEMENT:-.; Work D �,. <br /> / / `State ane <br /> 3 PUMP ,REPAIR: / / -State- Work Done <br /> ' DESTRUCTION OF WELL: Well DiameterAp roximate Depth G0 <br /> ter- De cribs terial .and Procedure tx- -5 -,fe p40 6 <br /> 1 I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> k 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- Sari 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 .af' my.knowledge and belief. 'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG OUTING ANDA FINAL INSPECTION. f <br /> SIGNED .*. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR D PARTMENT USE ONLY <br /> IPHASE�I i <br /> APPLICATION ACCEPT A - DATE Z � <br /> ADDITIONAL COMMENTS: . <br /> PHASE 11 GROUT INSPECTION PHASE FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION..BY. .. 'of DATE <br /> c <br /> E H 1426 Rev. 1-74 r -- lt/75_- -- <br />