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- .00 SAN JOAQUIN LOCAL. ff TH DISTRICT r <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. ,`Stockton, Calif. F <br /> j Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/�7 <br /> t. <br /> (Complete In Triplicate) �o 3- � �-1� <br /> Application is t8 reby` 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 /> JOB ADDRESS/LOCATION <br /> 3 " - . - CENSUS TRACT <br /> Phone 91G7 <br /> Owner's Name X591 . <br /> Address City <br /> f <br /> Contractor s Name <br /> " s .+License X0L3Phone - <br /> F <br /> TYPE-OF WORK'(-Check) i—NEW`WELL-�DEEPEN-/ / RECONDITION I I' -DESTRUCTION/ <br /> PUMP INSTALLATION / / PUMP REPAIR / / ! PUMP REPLACEMENT /� <br /> Other <br /> ,rrte,^, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER -LINES : .PIT PRIVY g_ - - . l U) <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> J OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC, WELL L2QL PUBLIC DOMESTIC WELL dU�2J <br /> INTENDED USE �:,.,. TYPE OF WELL CONSTRUCTION SPECIFICATIONS s <br /> Industrial i Cable Tool Dia. of Well Excavation o2 <br /> Domestic/private ! Drilled Dia. oftWell Casing <br /> ,.- <br /> Of <br /> Domestic/public I Driven Gauge ofCasing <br /> Irrigation •! L7 Gravel Pack Depth of-Grout Seal <br /> Cathodic Protection { Rotary Type of Grout -- <br /> Disposal Other Other Information <br /> Geophysical � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ✓ �`+ti'R �: -46 j <br /> Type of Pump . '`, ' H.P. S� l <br /> PUMP REPLACEMENT: / ./ State Work Done { <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 .f.urnish-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 of my knowledge;,and belief. I WILL CALL FOR A GROUT INSPECTION . <br />{ PRIOR TOG UTING AND NAL INS ECTION. <br /> SIGNED04 TITLE <br /> (DRAW PLOT PIM ON REVERSE SIDE) `...: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Is DATE 5 --7 7, . <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> - PHASE <br /> s r II GROUT.-INSPECTION 1r-' PHASE--II /FIN INSPECTION <br /> INSPECTION BY. ._ - _ DATE <br /> ,. INSPECTION BY DATE <br /> �. E H 1426 'Rev. ' 1-74 <br />