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04 SAN JOA.QUIN LOCAL HEALTH DISTRICT <br /> FOhf0FFICE USE: 1$01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S &J <br /> 7S- 44 <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 <br /> 1the Rules and Regulations of the San Joaquin Local Health District. <br /> � c � ., <br /> ;YOB ADDRESS/LOCATION :� { i� CENSUS TRACT <br /> 0 77 <br /> Owner's Name <.. - Phone: <br /> Address ,rte y City <br /> Cox:tr"actor s Name. I fr _.� .. .�_ --____.___` - License # ' '- Phoaee - r <br /> yII <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPqhj�-, <br /> _/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 - s <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY G�1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> '—.PROPERTY-LINE--, PRIVATEDOMESTIC WELL.. PUBLIC'DOMESTIC WELL <br /> INTENDED USE' TYPE OF WELL CONSTRUCTION SPECI 'IONS ' <br /> Industrial ► Cable Tool Dia. of Well Excavation, o <br /> Domestic/private ± Drilled ,j Dia. 6f Well Casing :--687 <br /> , <br /> Domestic/public ,.. Ghu'e`of`'Casin <br /> Irrigation Gravel Pack Depth ofLGrout;;Se'a' "' �1:4 <br /> Cathodic Protection Rotary 4 Type of Grout' l <br /> Disposal Other Other Information Geophysical ¢ Suiface Seal Installed B :4 i <br /> PUMP INSTALLATION Contractor <br /> Type of Pump : . . H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: L 7 State Work Done. *-- <br /> ,RES;RUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe-Material ..and Procedure <br /> } <br /> Ihhereby agree to comply with laws and regulations,of_the=San�oaquin-Vocal Health District <br /> n <br /> the State of- CalifoxnaertainYng 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 /> WELL DRILLERS REPORT of the well and notify them before puttingthe- well in use.. The above <br /> information is true to the•best of my knowledge and belief. I WILL CAI, FOR, A GROUT INSPECTION <br /> PRIOR TO CROU., NG x D _A FIN <br /> SIGNED j'a"' _ TITLE . .., <br /> (DRAW PLOT FLAN ON REVERSE SIDE) <br /> ,FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> B <br /> APPLICATION ACADDITIONAL COMMENTS.; �.���� .�� DATE <br /> CEPTED Y ,�: <br /> 2 . <br /> PHASE II ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ✓- DATE �/.� S`- INSPECTION- BY DATE <br /> qk E H 1426 Rev. 1-74 1-74 2M <br />