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f6 �� SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 466-678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �/7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> A ; (Complete In Triplicate) l(p.3 U70 -36 <br /> pplication is hereby made tthe San Joaquin Local Health District for a permit to construct <br /> and/ear 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 /> r- <br /> JOB ADDRESS/LOCATION � <br /> . . r/ ' CENSUS TRACT ' <br /> Owner's NameLL L { <br /> ' C Phone <br /> Address Gt t / l/c� City <br /> Contractor's Name -k ms . License # ��hone � <br /> s <br /> TYPE OF WORK (Check): NEW WELL/_ DEEPEN '/? RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O �: <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLk <br /> - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS c3 <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection l Rotary Type of Grout <br /> Disposal i Other <br /> Other Information _ <br /> Geophysical i Surface Seal Installed By. <br /> PUMP INSTALLATION.* Contractor ,�_! / <br /> Type of Pump 7- <br /> H.P. t <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP '.REPAIR: K/ State Work Done _ <br /> ES•TRUCTION OF WELL: Well. Diameter Approximate Depth # <br /> Describe Material and Procedure <br /> I hereby agree to compl with all laws and <br /> y regulations of the San Joaquin Local Hea1th 'District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS i <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 notifythem before <br /> em putting. the. well in.use.. The above <br /> information is true to the-bestof my.knowl d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING D A FIN _ IN E IO # <br /> ( W ON SE SIDE <br /> P 0 ' t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I s <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: S . <br /> PHASE II GROUT SPECTION PRASE III FIN INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE Z i <br /> ,YE H 1426 Rev. .1-74 + <br /> 3-7G Ju <br />