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k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA±OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ���� '��" O� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - <br /> 7� 8' 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -30-7 <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 :uLand ReAdations of t e Sat0"-pa i Loyal Health D strict. <br /> JOB ADDRESS/LOCATION U11161w v�' CENSUS TRACT c°,g)-o 1 <br /> Owner's Name Phone�, -2- � `� <br /> -� �. <br /> Address4424AI' City 6 Cly <br /> Contractor's Name 14 <br /> License D hone ^D Sr f I <br /> I <br /> TYPE OF WORK (Chick): 1 NEW WELL -/? DEEPE�N �/-T- /RECONDITION /_-7 DESTRUCTION /7 <br /> PUMP.•INSTALLATION / 7 PUMP REPAIR / PUMP REPLACEMENT17 <br /> Other'/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK �U- GEWER L ES dI T PRIVY <br /> SEWAGE DISPOSAL FIELD 1�ESSPOOL/SEEPAGE PIT OTHER ------ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLI DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ry CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia.of Well- Excavation <br /> Domestic/private Drilled Dial. of'Well Casing ; <br /> s Domestic/public Driven Gauge of Casing / s <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> t Cathodic Protection teary Type of Grouit�` r i <br /> Disposal Other Other Information [ 77 <br /> i,Geophysical ` 5uxf a eal Tn� ']led B :, ' <br /> { ti <br /> PUMP,1-NSTALLATION: jContractor ` -� <br /> A <br /> Type. of Pu c rV H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP iREPAIR: /7 State Work Done m __�...._ 1� i .. <br /> ES•TRUCTION OF WELL: Well DiameterM)Approx _mate Depth <br /> Describe Material and Procedure r ; <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 td or-regulating well construrtion: "4 Within FIFTEEN DAYSi . <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 /> info tion is true to the.be . my knin3ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ROUTING ANDA N E <br /> SIGNED r TITLE` 6 —es��'`�A2 <br /> DRAW.PLOT PLAN ON REVERSE SIDE ..t,.`. <br /> _ I <br /> `FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: 7 Z -- a_,"- <br /> PB4,II WUT INSFECTI -a PHA I AL NSPECTION <br /> INSPECTION BVdZZA11DATE INSPECTION BY DATE <br /> Pte.. <br /> •E H 142 '- • <br /> Rev. 1-74 -� -K <br />