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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: 1601 E. Haaiyltorz,.Ave. , Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued L-2-: , <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 heiein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andthe Ru s d Regulations o t Sari Joaquiin Local Health District, <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT +3 <br /> Owner's Names ~� U Phone <br /> 7-1 <br /> Address d City <br /> i <br /> License # Phone <br /> Contractor's Name ; <br /> , i <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/-7 RECONDITION_/T DESTRUCTION /7 <br /> PUMP INSTALLATION ',o PUMP REPAIR / / PUMP REPLACEMENT /— <br /> Other j/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK S LINES PIT PRIVY _ <br /> SEWAGE DISP IgELD CE POOL/SE PAGE PIT OTHER <br /> PROPERTY.-LINE PRIVA E DOMESTIC WELL PUBLIC DOMESTIC CATIONS : V <br /> INTENDED USE TYPE OF WELL. <br /> ONSTRUCTION. SPECIPITIO <br /> Industrial .. Cable Tool <br /> Dia. of We11.,Excavation { <br /> Domestic/Private D-rifled Dia. of Well Casing <br /> Domestic/public . 4 Driven Gauge.of .Casing .- <br /> Irrigation Gravel Pact Depth of Grout Seal T <br /> Cathodic Protection Rotary Typee of Grout :? <br /> Disposal Other ' Other- Information <br /> Geophysical ;. � urfaee Seal Installed B <br /> t PUMP INSTALLATION: Contractgr' <br /> Type of 'Pump H.P. <br /> PUMP REPLACEMENT: . / / State`Work'Done <br /> PUMP'REPAIR:-.' ` _-;/ j <br /> State'Work-Done--."` <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth - ' <br /> Describe Material and Procedure <br /> I hereb a ree to complp with all laws and regulations of the San Joaquin Local Health District . <br /> Y g <br /> and the State lof 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 Di.stri.c't a <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The abdve� <br /> information is rue tot bes af. ..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO G A INSP ION. TITLE <br /> SIGNED ,t <br /> P. PLAWON RSP SIDE <br /> OI��EPART T USE ONLY <br /> f PHASE Iy . DATE <br /> APPLICATION ACCEPTED BY. <br /> ADDITIONAL i.OHMENTS: <br /> Pli�►SE II GROUT INSPEC ON PHASE I'll/FINAL INSPECTION <br /> INSPECTION BY �;,.,_ <br /> DATE INSPECTION BY _ ✓ _ DATE - ZO <br /> i <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />