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11id <br /> SAN JOAQUIN LOCAI TH DISTRICT <br /> FOE;OFFICE USE: EJ j1601 E. Hazelton Ave, Stockton, Calif. <br /> Telephone: (209) 466--6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE -ISSUED <br /> 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 instal! the work herein described. This appxication 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 /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City ' , <br /> Contractor's Name ! i <br /> iK . itse !� : hone f <br /> TY _0i0�" WORK (Check) : N& WELL DEEPEN /__7 RECONDITIO _ <br /> N /7 DESTRUCTION /-7 <br /> PUMP INST TION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Otlh er k <br /> DISTANCE TO NEAREST: SEPTIC TANK S LI S f <br /> SEWAGE DISP S FIELD PZT PRIVY <br /> PROPERTY �� SS OL/SEEPAGE PIT OTHER <br /> LINE - PRIVATE I� MESTIC WELL ' PUBLIC DOMESTIC WELL � t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial —. Cable Tool Dia. of Well Excavation d y <br /> Domestic/private -Drilled Dia. of Well Casin e <br /> Domestic/public Driven Gauge- of Casing $ <br /> Irrigation Gravel Pack Depth of Grout Seaal <br /> Cathodic Protection ) Rotary <br /> Y Type of Grout <br /> Other Other Information <br /> Geophysical Surface Seal. Installed 'B <br /> , . <br />'UMP' INSTALLATION: Contractor <br /> Type .of Pump <br /> ,M - H.P. <br /> UNP REPLACEMENT: / I� State Work Done <br /> UMP—EPS: / /;' .State Work Done <br /> RUCTIflN OF L <br /> WEL; Wel]. Diameter � � Y. <br />�S+T ' <br /> " Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws an regulations of the San Joaquin Local Health District <br /> id the State of Californik pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> Eter completion of my work on a new well, I will furnish the San .Joaquin Local Health District a <br />'LL ,DRILLERS REPORT of the well and notify them before putting.the..well in-use.... The above <br /> iformation is true to the•�best .of. my..knowledge and belief. I WILL CALL FOR 'A 'GROUT INSPECTION <br /> 1OR' TO GROUTIN 'AND A FIN NSPECTION. <br />:GNED . ...�. ij TITLE <br /> {DRA PLOT PL ON ERSE S <br /> IM' FOR DSP TMT USE ONLY <br /> LASE I <br />'PLICATION ACCEPTED BY h i <br /> iDITIONAL COMMENTS: ;M DATE <br /> PHA1J,UT I PECTIO <br />'SPECTION BYPHA INS <br /> III F AL PECTION <br /> DATE l '— INSPECTION BY ATE 7 <br /> E H 1426 Rev. 1-74 ! T oat o14ro-77 <br /> 1./•a� nwc <br />