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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> TO-F �OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif." <br /> Telephone : (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 $rkk <br /> . S. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 10,&, $ <br /> (Complete In Triplicate) <br /> Application -is hereby made to the San Joaquin Local Health District for a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No.° 1862 and the Rul;Vx_:�,2t <br /> Regulations of the San Joaquin Lo aj Health District. <br /> JOB ADDRESS'/LOCATION 0 CENSUS TRACT C--4,f-0 Al ' <br /> Owner's Name d 0 Phone <br /> Address / U Cit <br /> Contractor's Na - 4_ H /(/ . 1 License #342-7N/Phone F10-4531 r <br /> X <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION / / ;. DESTRUCTION <br /> PUMP INSTALLATION 14 PUMP REPAIR/ / PUMP REPLACEMENT /rT <br /> Other / / AOv <br /> DISTANCE TO NEAREST: SEPTIC TANKVSEWER LINES PIT PRI <br /> ` SEWAGE DIOCA! FIELD/&?�, CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION •SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation +� <br /> ommestic/private - Drilled Dia. of Well Casing <br /> Domestic/public Driven + Gauge of Casing <br /> ` Irrigation Gravel Pack Depth of Grout S <br /> Cathodic Protection otary Type of Grout <br /> Disposal Other Other Information 4a <br /> Geophysical ace Seal Installed B <br /> � r <br /> PUMP INSTALLATION: ContractoAM <br /> Type of 'P H.P. <br /> Y <br /> PUMP REPLACEMENT: / / State Work Done <br /> s; <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 them before putting the .well in use..- The above <br /> info ion is true to the e t\of my knowledge and belief. I WILL CALL FOR'A GROUT INSPECTION <br /> PRIOR UTING A SPECT ON. <br /> SIGNED TITLE _ <br /> {DRAW T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT• USE ONLY <br /> - p � <br /> APPLICATION ACCEPTED BY7 / DATE J/! <br /> ADDITIONAL COMMENTS: _. 7 F r <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> G v <br /> 1177 _ - 2ME H 1426 - Rev. 1-74 -- _- -- - - - - - <br />