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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�.OFFICE USE: 1601 2�. Hazelton Ave. , Stockton, Calif. <br /> Telephone: , (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?S-4-3.54- <br /> , .� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Iasued /�7S <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 Joaqui <br /> County Ordinance ,No. 1862 aid the Rules and Re.gulationa of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> i /� 231- 1177 <br /> //]]2 /J 17� <br /> Owner's Name !-r r I-- Phone 1 J_/ - 1/ / / <br /> } y` air/ <br /> Address.. d Cit <br /> Contractor's Name License # (1� Phone <br /> :f _..:.. <br /> t <br /> TYPZ OF WORK (Check) : NE'W- EE L l DEEP.EN�/��coNAITIOX�1_ ,�DESTRUCTION-�f { <br /> ' —'SUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other # . .- <br /> DISTANCE TO NEAREST,: SEPTIC TANK Q ' SEWER LINES PIT PRIVY # <br /> SEWAGE DISPOSAL FIELD f 0�-.�—CESSPOOf;/-SEEPAGE SPIT' :. , I ..OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLICIDOMESTIC WELL <br /> INTENDED USE F�TYPE OF WELL " i CONSTRUCTION� SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia.of-We3`Z Excavation i \n <br /> Domestic/private Dril]ecl Dia.sof Well Casing s` <br /> Domestic/public, Driven Gauge of CasingA <br /> Irrigation Gravel Pack' Depth of_ Grout .Seal + <br /> Cathodic Protection n Rotary Type�of'Grout - } /]' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed ;B.Y t /l T T7s <br /> PUMP INSTALLATION: Contractor -` <br /> Type ,.of Pump R.P. , <br /> PUMP REPLACEMENT: . <br /> / / State Work Done � <br /> PUMP,�,RE�PAIR: 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 /> f <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. thre..well. in.use.... .The above <br /> information is true to the-best.of- my..knowledge and belief, I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AN . A FINAL NSPECTION, <br /> SIGNED �- •- TITLE . <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY w <br /> PHASE I <br /> f APPLICATION ACCEPTED BY �F . ' DATE <br /> ADDITIONAL COMMENTS: 1 <br /> ► PHASE II GROUT INSPECTION P I INSPECTION <br /> ,, INSPECTION BY DATE INSPECTION TE <br /> , A, <br /> �' E H l4 6 Rev'. 1-74' 1 LI/r�icii.,/ a�,. �zls <br />