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F � } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOF,.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,7 - 2_y__2. { <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. f <br /> JOB ADDRESS/LOCATION ' -'(J CENSUS TRACT Cr <br /> Owner's Name 7-t7",I 41 Lf " P'l Phone j <br /> Address City <br /> Contractor's Name „ =r9 License #t r @1 Phone <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN/--/- -RECONDITION /_/ _DESTRUCTIbI_' /_77 . <br /> PUMP INST CATION// / PUMP REPAIR / / PUMP REPLACEMENT _/7 <br /> Other <br /> DISTANCE TO NEAREST:. SEPTIC TANK ._10,r7SEWER LIKES/ PIT PRIVY --� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT T— 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 Drilled4 Dia, of Well Casing <br /> Domestic/public Driven J Gauge of Casing <br /> Irrigation Gravel Pack Depth-of-Grout •S-eals <br /> Cathodic Protec-tion Rotary Type of Grout BDY1_1 , , <br /> 4 - <br /> Disposal Other Other Information <br /> Geophysical Surface. Seal- Installed B fju <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump H.P. .. <br /> PUMP 'REPLACEMENT: / / State Work Done ,-` <br /> PUMP .REPAIR: / / State Work Done �I <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,.tlhe- San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well ''construction: Within FIFTEEN DAIS <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 welland notify them before putting the well-in use.' The above i <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN:SPECTLION:.3>/� <br /> SIGNED f � - TITLES <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR.-DEPARTMENT U5 ONLY <br /> PHASE I :� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> SE I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION B DATE INSPECTION BY .DATE p <br /> R H 1G7F n .. , - 7A : 1 /77 9M <br />