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(T /� SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) A66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 � - 794�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '9_�-Z6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District far 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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone 31 <br /> Address <br /> �• �i <br /> �� G _ h City <br /> License X2373 Phone 6 � <br /> Contractor's Name <br /> 'T <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / REINDITION / / DESTRUCTION (7 <br /> PUMFjINSTALLATION '/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other I I l <br /> r DISTANCE TO NEAREST: SEPTIC TANK �2,c! SEWER LINES E7 PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT o o OTHER <br /> PROPERTY LINE- P14VATE DOMESTIC WELL �, UBLIC DOMESTIC WELL <br /> INTENDED--USE- .----- _- T�'PR--0 ` =� •=`• ='`" ' --- -- ONSTRUCMON.�.-S.RECIF'ICAT.IONS <br /> Industrial }� Gable Tool Dia. of Wetl1Excavatian /Q <br /> �r <br /> Domestic/private Drilled Dia. of Well �Casing ., " <br /> Domestic/public Driven Gauge of Casing �n2 <br /> Irrigation �Pr-avel Pack Depth of G�ou� Sea .�'dCathodic Protection otary%5 Type of Groutj <br /> Disposal Other Other InfoLab on <br /> Geophysical Surface Seall 1�stalled B <br /> ` p ..INSxAI.LATI-0Contrao � - i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / F State Work Done <br /> PUMP .REPAIR: / /; State Work Doner f <br /> DESTRUCTION OF WELL: Welil Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4. <br /> I hereby agree to comply with all laws and regulations of the -Sari' Joaquin Local Health District <br /> and the State of California pertaining to or regulating well'clon6truction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish theSad Joaquin Local Health District i <br /> WELL DkILLERS REPORT of the well and notify them before puttijg the well in use. The above <br /> k information is true to the'best of my.knowledge and belief. WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR I , ANDA NAL INSPECTION. <br /> SIGHED TITLE i <br /> WT DRAW-PZ T' PLAN ON REVERSE SIDE) a• `I <br /> FOR DEPARTMENT USE ONLY] <br /> PHASE I I <br /> f � BATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: 1 S' <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT1,ON <br /> I INSPECTION BY ' DATE INSPECTION BY A DATE /d ! I <br /> cfil <br /> 3/76 <br /> E H 1426 Rev. 1-74 <br />