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,- ,.. <br /> FOR. �,J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .QFFICE USE: /�' 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> In Date Issued 1= =-�7 <br /> Application is Aereby made to the San Complete <br /> District for a <br /> and/or install the wank herein described... permit to construct <br /> jCounty Ordina c.e No. 1862 and the 'Rules and TRegulations tofnthe is SaneJoaquinin pLocaleHealthwith SDistract. <br /> eA961j)g) / OCAT or Gjfl1" l l�f� `s �_ k <br /> ysv_42zeaelCENSUS TRACT <br /> Owner's Name "7_ <br /> a �' Ph one <br /> Address � � ;; G <br /> City &0_kz1C1_�Se <br /> Contractor's Name � � <br /> License #,o�7;5��O�Phone . <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPENa' <br /> RECONDITION DESTRUCTION / <br /> / / _7 � <br />"* PUMP INSTALLATION L/ PUMP REPAIRPUMP REPLACEMENT /-7' <br /> Other % / ry <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY � f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL OTHER <br /> INTENDED USE TYPE OF PUBLIC DOMESTIC WELL CONSTRPECIFICATION <br /> Industrial UCTTON SSf Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout I <br /> Disposal <br /> Geophysical <br /> Other Other Information <br /> Surface Seal Installed B <br /> (� <br /> PUMP INSTALLATION: Contractor <br /> Type of .Pump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materialand Procedure Approximate .Depth t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health i—s rict <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 /> information is true to the best 'of my knowledge and belief.. I WILL CALL FOR A GROUT INSPECTION � <br />'RIOR TO GROU G AND A FINAL INSPECTION. <br />'IGNED <br /> TITLE J <br /> (DRAW PLOT PLAN ON REVERSE SID <br />'HASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY J ,% <br />,DDITIONAL COMMENTS: DATE S-71 <br /> PHASE I ROUT INSPECTION <br />.NSPECTION BY P S II FINAL TNSPECTI N ) <br /> DATE INSPECTION BY i <br /> DATE <br /> E H 1426 Rev. 1-74 1177 Ma <br />