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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �OFi,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `I-3/5 <br /> All Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C�53— bSo_O 2, � <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Di compliance inrco pliancea permit twith nSan uJoaquin <br /> PP <br /> and/or install the work herein described. This application � <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> � t� ENSUS TRACT ' <br /> JOB ADDRESS/LOCATION ; <br /> Owner's Name <br /> City <br /> Address r r <br /> r / <br /> �I:icense�`� - `hon <br /> 11 ,_(v <br /> k Contractor's_Name� <br /> DfEEPEN_/ / RECONDITION /_7 DESTRUCTION. /_7 D w: <br /> TYPE OF WORK (Check) : NEW WELL /IX Pte, PAIR / PUMP REPLACEMENT /� <br /> PUMP INSTALLATION / <br /> other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEn PRIVATE DOMESTIC W.ELLCON5TRUC LICTION SPECEIFICATONS <br /> INTENDED USE -TYPE OF WE r _ ; <br /> k Industrial j f a 1e Too1 , . of W_e11 Excavation . <br /> +E lic R Dia-. .of Wel1> Casing,-- ' <br /> yr56- 1111111 <br /> stic/private. Drilled <br /> Domestic/pub Driven Gauge'�of-. -Cas rig" �-- <br /> f Irrigation Gravel Pack Depth of Grout. Seal <br /> Cathodic Protection Rotary Type of Grout �-��- <br /> +. Other Other Information r <br /> Disposal Surface Seal Installed B <br /> 1 Geophysical t <br /> PUMP INSTALLATION: Contractor H.P. <br /> I <br /> TypeofPump <br /> OY <br /> PUMP REPLACEMENT: / S ateWork._Done - <br /> PUMP .REPAIR: / / Statet Work Done <br /> r ApproximatDepth. <br /> DESTRUCTION OF WELL: Well Diameter " <br /> Describe Material and Procedure <br /> F <br /> I hereby agree to comply with all' laws and regulations of the San "Joaquin Local Health District <br /> IS <br /> and the State of California pertaining to or regulating well -construction. Within FIFTEEN DA <br /> t 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 the well in use. ' The above <br /> M information i true to the bes my k-owledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GR N AN FIN SPEC ON. TITLE r <br /> SIGNED (DRAW PLAN ON REVERSE SID <br /> F DEPARTMENT USE ONLY u <br /> PHASE I DATE <br /> APPLICATION ACCEPTED %G, <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTIO <br /> PHASE IiT INSPECTION INSPECTION BY DATE ' �a <br /> INSPECTION BY A DATE <br /> f : 1/77 . 2M. <br /> 1 _71. - - -- <br />