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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�:oF'FICE IF 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (249) 466-6781 <br /> i <br /> APPLICATION FOR WEt1?CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 4 �—THIS-RERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? <br /> D J�L, Ate, (Complete In Triplicate) 0-70-0.3 <br /> Application is hereby made to thi"San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein ,described. This application ie made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of Local Health District, <br /> JOB ADDRESS/LOCATION S W A V%E rNSU3 TRACT <br /> Owner's Name 1%, Phone <br /> Address G. S` City <br /> 3 <br /> Contractor's Name License # hone b6'7b� <br /> TYPE OF WORK (Check): NEW WELL '/_7 DEEPEN '/_7 RECONDITION /__7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ PUMP REPLACEMENT <br /> II <br /> / Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> } SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> •' PROPERTY LINE PRIVATE DOMESTIC WELL, ' PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ' <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed By. f <br /> PUMP INSTALLATION: Contractor wL <br /> Type of Pump H.P. <br /> d . <br /> PUMP REPLACEMENT: .: /1 State Work Done ' <br /> 4 PUMP ,REPAIR: � � <br /> /vJ State Work Done. —it C_j t a. <br /> DESTRUCTION OF WELL: Well Diameter Approximate:.Depth <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 the Sta 11W <br /> of ' a fornix pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after comp etion of m work on a new well, will furnish the San Joaquin Local, Health District a <br /> WELL. DRIL RS REPORT o the well a of y em before putting - in.use... .The above <br /> informati n is t e t e be f m wl ge an f. I WILL CALL A GROUT INSPECTION <br /> PRIOR TO OU FINAL N 0 <br /> SIGNED F, _ TITd E <br /> . t <br /> _. <br /> tJ <br /> ` (DRAW PLOT PLAN ON REVERSE SIDE)'•-F ` <br /> OR DEPARTMENT USEONLY <br /> PHASE I r £ '.* <br /> APPLICATION ACCEPTED BYDTE 7 <br /> ADDITIONAL,COMMENTS: <br /> PHASE 11,GROUT INSPECTIONP INSPECTION zr <br /> INSPECTION BY "' ` DATE INSPECTION B DATE — y <br /> E H 1426 Rev. 1-74 r Zt/75 2M f <br />