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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFF GE USE: 16Q1 E. g,azeltan Ave. <br /> 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 <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 67 -Z.6U <br /> CENSUS TRACT j <br /> Owner's Name <br /> Phone <br /> Address _ <br /> City <br /> Contractor's Name <br /> - s- <br /> cense # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN ' -7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/� PUMP REPLACEMENT %f <br /> Other !% y,_* - <br /> DISTANCE TO NEAREST:,. 'SEPTIC TANK i <br /> r leo_ SEWER LINES �- PIT. PRIVY <br /> . - - _ ,,,_ .-._- ,-- SEWAGE.DISPOSAL FIELD CESSPQQL/SEEPAGE PIT OTHER <br /> .° FROP.ERTY LINE - PRIVATE.DOMESTTC WELL' PUBLIC DOMESfiIC WELL <br /> INTENDED USE TYPE 0 ELL CONSTRUCTION SPECIFICATIONS � <br /> atrial , Cable Tool Dia, of Well Excavation <br /> D&M—es fWpriiiaCeDrilled Dia. of Well Casing <br /> Domestic/pUtjli% Driven Gauge of Casing r^ <br /> Irrigation Gravel Pack Depth of Grout Sea] <br /> Cathodic Pro.tec.tion Rotary Type of Grout <br /> Disposal Other Other Information - <br /> Geophysical � Surface Heal�Installed B <br /> PUMP "INSTALLATIONo-- Contractor--' ' <br /> Type of Pump ' <br /> H.P. <br /> PUMP REPLACEMENT: .,, State Work Done <br /> PU L,.REPAIR: . / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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. 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 11 in.use. . .The above <br /> Information is true to the. st.of. my-knowledge and belief. I WILL CALL 'FOR A GROUT INSPECTION <br />'RIOR TO GROUTI AN A AL Cr <br /> SIGNED <br /> TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE .° <br />'HASE I FOR DEPARTMENT USE ONLY <br /> iPPLICATION' ACCEPTED BY DATE I <br />►DDITIONAL COMMENT ` <br /> PHA S E PHASE III FINAL--INSPECTION <br /> INSPECTION BYp <br /> , DATE �TNSPECTT ?I <br /> E H 1426 ►. 7-74 �40% <br /> ._ <br />