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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> !c. <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" Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> y . <br /> JOB ADDRESS/LOCATION G � �.� CENSUS TRACT <br /> :Owner's Name Phone ' <br /> Address <br /> City . . <br /> Contractor's Names '�c�r� <br /> _Li _��hone z�©3 <br /> TYPE OF WORK (Check) : NEW WELL 4ff DEEPEN /7 RECONDITION /-7 DESTRUCTION "/'7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/`7 PUMP REPLACEMENT /`J <br /> Other <br /> C .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT BOTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL s : CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> .," Drilled Dia. of Well Casing <br /> Domestic/public g •Driven :_:.;�-Gauge *f, Ca'sing- <br /> Irrigation Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection 1 " Rotary �,Typeriaf Grout <br /> Geophysical .s <br /> Disposal,. Other �' Other Information- <br /> Surf <br /> nformation- a <br /> � -�.�.. <br /> Surface-Seal Installed 'B ,, <br /> PUMP INSTALLATION:; Contractor R <br /> i Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State, Work Done <br /> PUMP '.REPAIR: + � <br /> / / ••'State Work Done _r <br /> DESTRUCTION OF WELL: ;,Well Diameter- , . <br /> ,Describe Material and Procedure Approximate Depth <br /> I hereby agree to omply with all ,laws and regulations of the .S_an�Jn��j.uin�I.ocalm:HeaL-th District-= <br /> and-"the=-Sta•te�of--Calf-fornia�-psi"t ntng o_or regulating ll1 ''cons trufitiote. 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."well. in.use The' above <br /> information is true to the-best'lo£lm ..knowledge and belief. I WIL L FOR ROUT INSPECTION <br /> PRIOR TO GRO NG AND A FI INSPE IO <br /> SIGNED a , 0, v,,, <br /> TITLE <br /> )RAW POT LAN ON VERSE SIZA� <br /> F . `DEPARTMENT USE ONLY <br /> PHASE I <br /> ;APPLICATION ACCEPTED BY li <br /> ' DATE <br /> ADDITIONAL COMMENTS: <br /> Fag II G UT INSPECTWN PHASE III U INAL INSPECTION <br /> INSPECTION BY PATE INSPECTION BY Z2 C44,444, DATE -; Q <br /> —76 <br /> E H 1426 Rev. 1-74 4 _ r 1./?C om <br />