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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2, <br /> THISPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> the San Joaquin 'Loca1 Health District for a permit to construct <br /> Application is ►ereby made to: <br /> and/or install the work hereiin described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andPthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 7 � 5 CENSUS TRACT <br /> 1 Phone � J <br /> Owner's Name <br /> .' City <br /> Address <br /> License 11.2,r,60 _ Phone g!�2.T-"19"l <br /> Contractor's Name <br /> TYPE OF WORD (Check) : NEW WELL I I DEEPEN I / _RECONDITION / I DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / I �- <br />{ DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLSTIC WELL <br /> PUBLIC <br /> I SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial E} Cable Tool Dia, of Well Excavation <br /> t Domestic/private Drilled Dia, of Well CasingGau a of Casing -- <br /> Domestic/public Driven g <br /> ... - .i}. _ - Grayel :Pack -_ . T " Depth-of Grout" Seal <br /> g. Irrigation _ - <br /> Cathodic Protection- '4 Rotary Type of Grout <br /> Disposal .! Other _ Other Information <br /> Geophysical Surface Seal Installed By: \ <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type ,of Pump <br /> MPUMP REPLACEMENT: State' Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> E Describe Material and Procedure ; <br /> . 1 hereby agtee- to comply with all laws and regulations of the San Joaquin Local Health istrict ' <br /> and the State 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 Sanr.Toaquin Local Health District 's <br /> above <br /> WELL DRILLERS REPORT of 'the well and notify them before pu tlng <br /> l WILL CALL FOR A GROUT. the well in use. eTNSPECTTON <br /> ) information is true to the best of my knowledge an . <br /> PRIOR TOG UTING AND A FINAL INS ECTION.2-527 i—112 TITLE <br /> ( SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> y FOR DEPARTMENT USE ONLY p <br /> PHASE I DATE A <br /> APPLICATION ACCEPTED BY <br /> 1ADDITIONAL COMMENTS: "•` HA II INSPECTION <br /> PHASE IT GROUT INSPECTION INSPECTION B DATE <br /> tINSPECTION BY DATE <br /> I <br /> 1/77 <br /> _ 2M <br />