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d )V/ SAN JOAQUIN LOCAL'.HEALTH DISTRICT <br /> FOB; FICE USE: 1601 E. Hazel' on :P:ve ', Stockton, Calif. r <br /> Telephone: ",(209)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S' o <br /> THIS PERMIT EXPIRES- 1-YEAR FROM DATE ISSUED Date Issued9-_6`:71^� <br /> (Complete In-Triplicate) <br /> Application is hereby made to the San Joaquin Local:iHealth District for a permit to construct <br /> and/or install,the work herein described. This application is made in compliance with San Joaquin <br /> Countq Ordinance No. ,1862 and the Rules an Regulations of:.the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> owner's Nam Phone <br /> 4 �Address - `aZ 7 r l3S ®,2 sT' , �... City re 2 <br /> Contractor's Name License ##` 3 Phones" ?G . <br /> TYPE OF WORK- (Check): NEW WELL /7 DEEPEN. /-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / „ PUMP REPAIR PUMP REPLACEMENT' /_T . <br /> ► Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ..- PROPERTY LINE PRIVATEDOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <br /> }e <br /> Industrial,,, Tool `'Dia. of Well Excavation <br /> Domestic/private " Drilled Dia: of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 'Gravel Pack Depth of Grout Seal , <br /> ':"Cathodic Protection Rotary Type of Grout <br /> { Disposal. Other Other. Information _ <br /> Geophysical Surface Seal Installed BY: <br /> r <br /> PUMP INSTALLATION: Contractor- tri. •. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Domer <br /> � Depth <br /> � <br /> 2E&TRUCTION OF WELL. Well Diameter App proximate p i <br /> Describe Material and Procedure ' <br /> I hereby agree .to comply with all laws and regulations of the San Joaquin Local. Health District <br /> and O eiState 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 /> i WELL DRILLERS REPORT of the well and notify them before putting.. the.well in-use.. The above <br /> information is true to the best knowledge, and belief. I WILL CALL FbR�A GROUT INSPECTION <br /> PRIORRO TING AnD A FINAL INSkk7AQ6,� z9) . <br /> SIGNED TITLE i <br /> {. PLOT PLAN 0 ERSE SIDE <br /> FOR.DEPARTMENT. USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE �7"i <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT._I SPECTION PHASE III/FINAL. INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> '-i E H 1426 Rev. : 1-74 1-74 2M <br />