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3 .'C 1 / f; SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> F 4OFFI E USE. YYy// 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l F71'0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S Z-75— <br /> (Complete In Triplicate) 0573-0 <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 Joaquin <br /> M County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> (SY1 o A)- V7W-,(_�7VN , <br /> JOB ADDRESS/LOCATION / �y7+-�. y 7J��C CENSUS TRACT <br /> Owner"s s Nk" Phone "7� ., r'4 <br /> k f �r�h�..� 7 <br /> Address o city, .�fr ' <br /> Contractor's Name License #ILL Phon-e3 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN j-7 RECONDITION /-7 DESTRUCTION <br /> AL <br /> PUMP INSTLATION REPAIR PUMP REPLACEMENT <br /> Other I 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL �• <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial ,Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of. Casing <br /> C Irrigation `—'Gravel Pack Depth of Grout Seal <br /> Cathodic Protection', Rotary Type of Grout <br /> Disposal Y t Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLA2ION: Contractor ' <br /> Type of Pump H.P. m <br /> r <br /> PUMP , � r <br /> State `Work Done �e..- <br /> �I?-tIiEPAIR: 1--ftatewMork-Done -„ <br /> �._.d. <br /> ESTRUCTION OF WELL: Well Diameter 90 r Approximate Depth <br /> Describe Material and Procedure <br /> c f . <br /> E <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 <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 TO GROUTI D A FINa INSACT ON. <br /> SIGNED TITLE <br /> TgDA6W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY 4 J, DATE <br /> ADDITIONAL COMMENTS: r -- <br /> PHASE II U ISP , IO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M. <br />