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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE ;USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> j Telephone: (209), 466 .6781 <br /> APP %ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7_�/�&z- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicationtis 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 J Gl ` ' r7 G6lre^ CENSUS TRACT <br /> Owner's Name �� B. �'YY/ Phone f � <br /> Address ' .. -. .. City, <br /> Ci �`1t <br /> Contractora Name /E r /rl� g�S d /1 License #We�1 Q�hone,!�i -�v2 <br /> Al <br /> TYPE OF WORK (Check): NEW WELL' 'DEEPEN--/7 RECONDITION�._ DESTRUCTION f 7 <br /> PUMP INSTALLATION j� PUMP REPAIR'/� PUMP REPLACEMENT /7 <br /> Other' /_/ <br /> DISTANCE TO;NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP05AL FIELD =:.CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL __P_UBL1C DOMESTIC WELL �l <br /> INTENDED USE TYPE OF WELL yCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privatei"u Drilled Dia. of Well Caaing -: <br /> Domestic/public Driven Gauge of Casing, <br /> Irrigation Gravel! Pack Depth of._ Grout Seal <br /> Cathodic Protection Rotary Type of Grout v <br /> Disposal Other i Other Information <br /> � - Geophysical Surface 5ea7=InstaledTBy.:..., <br /> PUMP INSTALLATION; Contractor ~� <br /> T"ppe .of Pump - ----__ - H.P. s <br /> 4. <br /> PUMP REPLACEMENT: • b.j State Work Done <br /> PUMP 'REPAIR: State- Work,Done } <br /> DE&TRUCTIONPOF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I' hereby agree to complyIiwith all laws and regulations--of-the San Joaquin Local_ Health�Distr.ict. <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"wb11. in.use.... .The above <br /> information is true to the.best.of.-my.knowledge and belief. ' I�WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A VIflkl,INSPECTION. <br /> SIGNED TITLE_ - ! <br /> tiM DRAW PLOT PLAN ON REVERSE SIDE <br /> „ . ;FOR DEPARTMENT USE ONLY <br /> PHASE I } <br /> APPLICATION ACCEPTED BY DATE <br /> ADDIT.IONA:L`COMMENTS 7-7 <br /> ;4 PHA INSPECTION PHASE SPECTION <br /> INSPECTION BY DATE Z.—,? INSPECTION",,BY'a. . E <br /> 4 <br /> E H 1426' Rev. 1-74'� . . ..__. - <br />