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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - <br /> ' FOS OFFICE USE: CT 1z <br /> 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE <br /> RMITi Permit No. <br /> r ✓ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3-7 <br /> R ' { (Complete In Triplicate) -----� <br /> Application) is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the1work 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 ,�/ - ' ' <br /> o- { CENSUS:TRACT <br /> Owner's Name / /k0V4__ 7SPh ��"' � <br /> / jj��'' one <br /> Address (� <br /> City �d <br /> Contractor's Name License # /�2 373 Phone <br /> i #t-6� zs <br /> TYPE OF WORK.,_ <br /> (Check) <br /> :—NEW NEW, DEEPEN17 RECONDITION /_7 DESTRUCTION FfY <br /> PUMPINSTALLATION / J PUMP REPAIR /� PUMP REPLACEMErTOther `/ / <br /> DISTANCE TO NEAREST: SEPTIC �TANK SEWER LYNES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY _ <br /> PROPERTY LINE - PRIVATE DOMESTICSWE�L�SEEPA�UBLiC DOMESTICrW�ELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ...Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public IDriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection { Rotary a of Grout <br /> Disposal Other <br /> —Geophysical. Other Information <br /> .. � Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. . <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP '.REPAIR: /7 State Work Done <br /> .. JWell Diameter _"°'�"_"�"'�"'"..'� .--�-., _ <br /> Approximate Depth yT <br /> Describe Material and Procedure 7-70) -- <br /> I hereby agree to comply withail 1a ws and reg ions of he San Joa u n Loc <br /> al rict <br /> and the State of California pertaining to or regulating well construction. WithinaFIFTEENfth tDAYS <br /> after completion of my work on: a new well. I will furnish the San Joaquin Local Health TEENDistrictD <br /> WELL DRILLERS REPORT of the well and notify them before a <br /> informationOaR is true to the-best o£ my knowledge and belief. WILL CALL FOR A GROUT eabove <br /> IN INSPECTION <br /> PRIOR TO GROUTING ANTh <br /> DA FINAL INSPECTION, a <br /> SIGNED � <br /> TITLE <br /> �. DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I PARTMENT US ONLY <br /> APPLICATION ACCEPTED $ ` <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHOS III FINAL IN <br /> SPEC ION <br /> ., DATE INSPECTION. B DATE <br /> rZ <br /> E H 1426 Rev. 1-74 (JV'BL- <br />