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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 San Joaquin, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> //! <br /> JOB ADDRESS/LOCATION � 1i 0 � CENSUS TRACT <br /> Owner's Name <br /> Address .3 d Z!fte, Gee- / e61:1 L_ City' <br /> Contractor's Name �/I�G�-� %4C -- -- License 09Phone <br /> TYPE OF WORK (Check): NEW WELL g DEEPEN '/7 RECONDITION F7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR / J pump REPLACEMENT /7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK /.2-U SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -: PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE-OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial °a Cable Tool Dia. of Well. Excavation J17 �1 <br /> Domestic/privateDrilled , Dia._of We11�Casing �, <br /> Cauge1Casing /O <br /> Irrigation Gravel Pack Depth of Grout,,Seal <br /> Cathodic Protection- Rotary Type of Grout' <br /> Disposal ' Other Other Information <br /> Geophysical 41— Surface Seal Installed BY: _--- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / c ~' H.P. / ,57— <br /> PUMP <br /> .SPUME REPLACEMENT:... /.../__ .State Work Done- 1% <br /> PUMP .REPAIR: M / State Work Done } <br /> 9ES1TRUCTION 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 a <br /> WELL DRILLERS REPORT of the well and notify thea before putting--the..well. in.use.... The above <br /> information is true to-the,best.af knowledge. and belief. I WILL CALL FOR'A 'GROUT- INSPECTION <br />; PRIOR TO R I AND A FI INSPEm ON. <br /> SIGNED fi• i. TITLE 'l <br /> F <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLYjk IL <br /> PRASE I <br /> APPLICATION' ACCEPTED BY DATE <br />' ADDITIONAL COMMENTS: <br /> F P I"ROUT INSPECTION PHA§ I YLM4 INSPECTION <br /> INSPECTION BY . DATE INSPECTION BY DATE <br /> -i B x/1426Rev. 1-74_: i�_4a4 h/75 2M <br />