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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0—jOFFICE USE: 1601 E. Hazelton' Ave':,4Stockton, Calif. <br /> Telephone: (209')`::466 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THUS :PERMIT EXPIRES l,_YEAR FROM DATE ISSUED Date Issued <br /> i' (Complete Int Triplicate) f <br /> Application is hereby matte 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 d the.Rules. ant Regulationa of toe San Joaquin Local Health District. <br /> / 4 CLQ a 2 w��+, 0 11 -0 v6 7*a-& <br /> S <br /> .TOB ADDRESS/LOCATION r 1 S - S do . .: `x t '�� CENSUS TRACT _ <br /> . .T - - `•*..�C - �'«"' "fid; 1 <br /> ` a (:Z '.rte.►. , <br /> ., f .� Phone <br /> Owners Name <br /> ��.. h!Tn.`�� ' � , x, City 4.SC jq,Lta�) <br /> Address l <br /> Contractor's Name License ? O Phone <br /> TYPE OF WORK (Check):' NEW WELL/_7 DEEPEN -/_7 RECONDITION /_7 DESTRUCTION % <br /> PUMP INSTALLATION / / PUMP REPAIR _4' PUMP REPLACEMENT <br /> Other', / / <br /> DISTANCE TO NEAREST: .;SEPTIC,TANK� e� SEWER LINES PIT PRIVY <br /> SEtA:6 ,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER R� <br /> PROPERTY L NE= PRIVATE-DOME3T-1-C-a-LL .—Q — ' LIC BONESTICTWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private i Drilled Dia. -of Well Casing <br /> Domestic/public ;! Driven Gauge of Casfhga, ; <br /> Irrigation , A Gravel Pack Depth ofiGrout Seal <br /> Cathodic Protection i Rotary Type rout <br /> Disposal I Other Other Information <br /> Geophysical ' Surface Seal,Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> - ------Te41. MP H.P. <br /> PUMP REPLACEMENT: ? / / ' !State Work Done <br /> J <br /> PUMP REPAIR: / (.State Work Done_ v <br /> JES•TRUCTION OF WELL: Well Diameter k Approximate Depth <br /> Describe Material and Procedure) <br /> I hereby agree to comply with all laws and regulatipnsfof the San Joaquin Local Health District <br /> ' and the-State of California pertaining to or regulat,irig 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 putting the.-well in use.. The above <br /> information is true to the-best of my.knowledge and belief. I WILL CAL_4 FOR A GROUT INSPECTION <br /> PRIOR TO GROUT G k2D A N INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> :FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: � <br /> PHASE If GROUTiINSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY i DATE INSPECTION BY 94_4-•-- DATE / :� � <br /> ,� ,:,E4H 1426 Rev, 1--74 . 1-74 2M <br />