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- � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE 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 Date Issued /--XW <br /> I (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 /> -s/i16 /moi'/za R4 <br /> JOB ADDRESS/LOCATION 9 J <br /> a CENSUS TRACT <br />�. Owner's Name <br /> Phone <br /> Address 7 ; 57 <br /> vg's City <br /> Contractor's Name I License It Phoney - <br /> we <br /> t <br /> TYPE OF WORK (Check) : NEW WE DEEPEN /_/ RECONDITION /�f DESTRUCTION /7 <br /> PUMP INS AL ITION'/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other ;/ / N <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK ¢SD SEWER LINE4i ! PIT PRIVY <br /> SEWAGE DISPO AL FIELD � CESSPOOL/SEEPAGE -PIT OTHER T <br /> PROPERTY LIA/02'PRIVATE DOMESTIC WELLfJ-,0 PUBLIC`DOMESTIC. WELL �+ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 <br /> Irrigation LX Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal f Other Other Information ' i <br /> Geophysical LgA, Pu A,1 An _ <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION; Contrjctor F <br /> Type ofPump H.P. 4 <br /> PUMP REPLACEMENT: <br /> / / State Work Done ; <br /> PUMP .REPAIR: / / State Work Done <br /> uiv <br /> DESTRUCTION OF WELL: Well DiaAme r Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> I hereby agree to comply withlall .laws 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 /> information is true to a es f. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO IN AND A I PECTION. <br /> SIGNED TITLE <br /> ti (DRAWLL- <br /> PLOT PLAN ON REVERSE SIDE) (i <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY .- <br /> ' <br /> APPLICATION ACCEPTED BY k DATE 7 <br /> ADDITIONAL COMMENTS j <br /> P I GRO T INSPECTION PHASE I/FIN INSPECTION - <br /> INSPECTION BY TE f.- 3 a --72P INSPECTION BY DATE 74F <br /> �E H 1426 Rev. 1-74 ' 1177 `_ <br />