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C' v f <br /> I' 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. W_ <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 Sen Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the Saar Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z r I <br /> �✓4 CENSUS TRACT <br /> Owner's Dame "� a <br /> Phone - 7(3 <br /> Address <br /> d ' City '- r4,�. F <br /> Contractor's Name �.� <br /> License #/G 13? Phone 3 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION _ DES <br /> /_7TRUCTION /- <br /> ;P�7MP INSTALLATION / /PUMP REPAIR -/� PUMP 4 PLACEMENT %T <br /> ,jOt�her /% <br /> DISTANCE TO NEAREST; <br /> SEPTIC TANK gTO SEWER LINES—M PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE �fT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL­­ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Exca*ation <br /> Domestic/private s �! <br />� Drilled �, Dia. of Well Casing <br /> Domestic/public Driven ",Gauge of, G ixi <br /> lrri aGi�n g .. - 4d,.,. ...— <br /> g n,n rave-1 Pauk-T------Dep'th�of-Groat-Se 1`� i <br /> Cathodic Protec ion, . [ . Rotary Type of Grouts rt <br /> Disposal <br /> Other <br /> r Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: e <br /> � Oo.ntractor . <br /> ripe`"of -Pump 3, IQH.P. <br /> PUMP REPLACEMENT: , '% tate' 'Work Done <br /> i, <br /> PUMP-REPAIR: % -Sta.te Work Done <br />)ESTRUCTION OF WELL: 4We11 Diameteroximate Depth r <br /> ,,Deperibe Material and Procedure ; <br /> s <br /> I hereby agree to c 1y iwith all laws and regulations of the San Jodquin Local Health District E <br /> and the State of Cali y s pertaining to or regulating well "construcltion. Within FIFTEEN DAYS <br /> after completion of m work on a new well, I will furnish the San Joaquin Local Health District a <br />'4ELL DRILLERS REPORT r f tie well and notify them before putting. the."well. in.use.... .The above' <br /> Lnformation is t tc the•best -of my- knowledge and belief. I WILL � L 'FOR A -GROUT INSPECTION <br />'RIOR TO'GROUTI A Fi' SPECTION <br /> SIGNED TITLE ` <br /> ``'� 7j (DRAW PLOT PLAN ON REVERSE SIDE 4 <br />?RASE I FOR DEPARTMENT USE .ONLY <br /> WPLICATION' ACCEPTED BY / DATE <br /> IDDITIONAL COMMENTS: uM - I <br /> PHASE II GROUT 'INSPECTIO PHASE III FINAL INSPECTIO <br /> INSPECTION BY _ /� . DATE . INSPECTION BY C DATE <br /> EwH 1426 Rev. 1-74 !x/75 _2M <br />