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,.. SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FOF OFFICE'USE: 1601 E. Hazelton Ave. , Stockton, Calif, v <br /> Telephone: (209) 466-6781 ��_/�1� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: <br /> o�c 2 2,:1977 <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /l �....� CENSUS TRACT <br /> a <br /> Owner's Name :/"/ 7 ti/l Phone <br /> Address ) City <br /> License ®' 'hone <br /> Contractor s NameT U ' "�� -----� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP` <br /> " REPAIR PUMP REPLACEMENT -7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC , Q SEWER LINA PIT PRIVY <br /> NC <br /> E7DISPOS FIELD Q� CESSPOOL/SEEPAGE PIT OTHER <br /> 'SEWAGE A� <br /> PROPERTYAIN PRIVATE DOMESTIC 'WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION -SPECIFICATIONS <br /> Industrial ' Cable Tool Dia, of Well Excavation. Q W <br /> Domestic/private Drilled Dia. of Well Casing <br /> �J (U <br /> Domestic/public Driven Gauge of Casing — /"7. <br /> F. Irrigation _ 1 Gravel Pack Depth of,., Seal rz) , <br /> aF <br /> Cathodic. Protection 1 v Rotary Type of -Grout <br /> Disposal Other Other Information ' <br /> Geophysical ..,_ Surface Seal Installed lay: /gym <br /> PUMP INSTALLATION: Contractor �d .: <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT. r--/—/—S-t-a-te -Work Done <br /> PUMP .REPAIR: / / 'State Work Done ` <br /> 7 <br /> Approximate A Depth <br /> DESTRUCTION OF WELL: WellI Diameter <br /> pp <br /> Describe Material and Procedure <br /> jj <br /> I hereby agree ree 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 worklon a new well, .j will furnish the-.San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the�.well and notify them before putting the well in use. The above <br /> information is tru the best of m ..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI AND -;A6�L-fIN-ECTI N <br /> SIGNED ., TITLE . <br /> RAW PL0VFLAN ON RE FRSE SIDAk <br /> E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `' DATE Z 'L <br /> t APPLICATION,ACED W <br /> j ADDITIONAL COMMENTS: <br /> 1 P E II GR UTf NSPECTION - Y PHASrin III INAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE q,- <br /> `` E H 1426 Rev. 1-74 ,' }- <br />