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SAN JOAQUIN LOCAL. HEALTH DISTRICT „ <br /> FOR.OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 r.a ��/a� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> P <br /> THIS PERMIT EXPIRES I, YEAR FROM DATE ISSUED Date Issued /01/-77614 < (Complete In Triplicate) ' <br /> Application is tereby 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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the-Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION, yea-AV �p CENSUS TRACT <br /> Owner's Name �inr Phone SSS 9- ? <br /> Address City <br /> Contractor's Name License !� Phoned - <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN- / RECONDITION /_7 DESTRUCTION /_7m PUMP INSTALLATION /�/."PUMP REPAIR / / PUMP REPLACEMENT F <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK L �i SEWER LIMES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER T��1 <br /> ", .PROPERTY LINEy9_'VRIVATE DOMESTIC WELLS +PUBLIC DOMESTIC WELL <br /> INTENDED USE., TYPE OF WELL CONSTRUCTION SPECIFICATIONS f, <br /> `Industrial°' Cable Tool Dia. of Well Excavation <br /> k Domestic/private Drilled Dia of Well Casing-yfp <br /> Domestic/public Driven -Gauge o'f--Casing44 <br /> " <br /> Irrigation Gravel Pack Depth of Grout Seal U » <br /> Cathodic Protection. Rotary t1Type of Grout <br /> Disposal Other Other Information/ N4 CI .4rW_ <br /> Geophysical Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> M G <br /> Type of Pump s 0, h ,.-eit-,Z.cJ[,- H.P. <br /> �. <br /> i Y <br /> PUMP REPLACEMENT: 'y / / State Work Done y <br />�PUMP '.REPAIR: T / / State Work Done - <br />� DES,TRUCTION OF.WELL: Well Diameter Approximate Depth <br /> Describe Material and' Proci--dure . <br /> I hereby agree to comply with all lawns and regulations of the San Joaquin Local, Health 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 />' informationtrue to he bes of k wl dge and belief.--I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OU D INAL SP IO - <br />' SIGNED TITLE <br /> ` <br /> � (DRA4 PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE;.ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIU TION PHASE /FIN INSPECTION <br /> INSPECTION---BY- -DATE-- -- -` —INSPECTION` BY D E <br /> E H 142'6 Rev. 1-74 - i f 77 <br />