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(/� �,/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORfOFFICE USE: ' 7/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �-.3a74J j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S76 <br /> 0 6 <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 <br /> ONo. 1862 and the Rule d Regulations of the San Joaquin L al ealt_h/District. <br /> IqJ6Chi►-�-c.�' /� �g-e, Ai <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ZL 0lq 1 { <br /> Phone Co <br /> Address <br /> Contractor t s Name License d So/a3 Phone Z2— 39 ( <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN /7 RECONDITION /? DESTRUCTION /_ <br /> PUMP INSTALLATION / UMP REPAIR /_ PUMP REPLACEMENT <br /> Other /_7 - -- <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWE LINES PiT PRIVY <br /> SEWAGE DI AL FIELD ESSPOOLISEEPAGE P T OTHER <br /> PROPERTY LINE - PRI V TE W14ESTIC i&L /PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL ',,CONSTRUCTION SPECIFICATIONS \ <br /> Inilustrial 1 Cable Tool Dia: of Well Excavation 7 <br /> ' omestic/private ' r Drilled I/ Dia. of Well Casing \� <br /> Domestic/public Driven - Gauge of Casing. <br /> Irrigation ' Gravel Pack , Depth of Grout S Q <br /> Cathodic Protection 1 f wry '- ' Type of Grout <br /> Disposal Other 'Other Information <br /> Geophysical 1 w E ace Seal umtailed BY: <br /> PUMP INSTALLATION: Contractor f <br /> Type of P •P• `, <br /> PUMP REPLACEMENT: /% State Work.,Done <br /> t <br /> PUMP *REPAIR: /7 State Work Done <br /> ES•TRUCTION OF WELL:. Well`Diameter f 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 <br /> WEL DRILLERS REPORT of the well An4 notify them befbre putting the.-well in use.. The above <br /> info rmkcion is true to t my owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND A IN PE IO . CV <br /> SIGNED - <br /> TITLE` -� <br /> W PLOT P N REVERSE SIDE)FOR DEPARTMENT USE ONLY <br /> P I <br /> APPLIC CEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION . PHASE III FINAL INSPECTION <br /> INSPECTION BY ,dj DATE k ;'INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 k j �� 1 .74 2M <br />