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SAN JOAQUIN LOCAL HEALTH D <br /> FOF�;OFFICE USE: DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r,l' R7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��77 <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 rude in compliance with San Joaquin <br /> County Ordinance No. ala&n <br /> Rules and Regulations of the San JoaquinLacal Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br />` Address rC Q 3 1'� S <br /> City - <br /> 07 <br /> ity . <br /> Contractor's Name I 1 p ,'r <br /> �U cense © <br /> r Li <br /> _ Phone ll(f-,3 3.3� <br /> TYPE - - <br /> OF WORK (Check): NEW WELL ' DEEPEN17 RECONDITION / DESTRUCTION 1-7 <br /> PUMP INSTALLATION " _7 PUMP REPAIR -1-7—PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD�, CESSPOOL/SEEftGE PIT OTHER <br /> INTENDED USE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL.'. PUBLIC DOMESTIC •WELT, <br /> TYPE OF WELL CONSTRUCTION <br /> Industrial Cable Tool Diaof Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing /,, �� <br /> Domestic/public Driven <br /> IrrigationGauge of Casing <br /> Gravel Pack Depth of Grout Sea,,' —". --- <br /> Cathodic Protection � j::::: Rotary <br /> Disposal <br /> Geophysical'' Other o€ Grout <br /> Other Other Information ' <br /> -��--- <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump <br /> H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP ,REPAIR: /_ State Work Done , <br /> _ -. �:�---,.-:..._„-�--.:� -----.-;-- <br /> DES:TRUCTION OF WELL: Well. Diameter - <br /> Describe Material and Procedure Approximate Depth_ <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 a <br /> JELL DRILLERS REPORT of the well and notify them before putting..the..well. in.use.... .The above <br /> Lnformation is true to- the-best-of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO G T G AND,:A FINAL INSPECTION. <br />'IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE . <br />'HASE I FOR DEPARTMENT USE ONLY k <br /> SPP IL`CATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS b,b, One DATE <br /> PHASE II GROUT INSP CTIONI <br /> NSPECTION BY PHASE III FINAL INSPECTION <br /> DATE _ INSPECTION BY DATE <br /> E H 1426 Rev. :1-74 <br />