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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR,OFFLOE USE: ' 1601 E. Hazelton Ave. , :Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> z7�6� <br /> ! � THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t Date Issued <br /> Application is Aereby made to# the San (Complete <br /> Local Triplicate) <br /> District for a permit to con <br /> struct <br /> and/or install the work herein described. This application ismade in compliance with San Joaquin <br /> County Ordinance No., i862 andtthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o. <br /> 486SUS TRACT . <br /> Owner's NamZZ e N <br /> Phone <br /> Address - S <br /> City c TcVZ <br /> Contractor's Name I License #,� Pho0e r _ /S ' <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN/ / RECONDITION A DESTRUCTION /� 77 <br /> PUMP INSTALLATION / / PUMP REPAIR f / PUMP REPLACEMENT <br /> Other / / <br /> /. <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 y Cable Tool Dia, of Well Excavation <br /> it <br /> Domestic/private Drilled Dia. of Well CasingNt <br /> Domestic/public 1 Driven -� Gau a of Cas n fI <br /> Irrigation _ g gam- - <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic .Protect_ ion ,Rotary _ Type of Grout �~ <br /> Disposal If Other <br /> Other Information <br /> iGeophysical - -- <br /> Surface Seal Installed By_- <br /> PUMP INSTALLATION: ��✓/� <br /> Contractor ' ._ <br /> i <br /> Type of Pump <br /> c <br /> PUl"P REPLACEMENT: .State. Work Done <br /> PULP. . - <br /> REPAIR:- State -Work Done k t <br />)ES-TRUCTION OF WELL: Well Diaiaeter <br /> . Describe Material and Procedure Approximate Depth <br /> C Hereby agree to comply with all laws and regulations of the San Joaquin Local Health DisCrict , <br /> ind_"the State of California pertaining to or regulating we11 ..construction. Within FIFTEEN DAYS <br /> 3f6pir completion of my work on a new well, I will furnish the San Joaquin Local Health District a " <br /> JELL DRILLERS' REPORT of the well and notify them before putting the. well in.use. Thi above <br /> Information is true to the b t my wledge and belief. I WILL CALL FOR A GROUT INSPECTION- <br /> RIOR T 0 TI G AN 'A FIN I EC <br /> iIGNED. TITLE �- <br /> W PLOT PIAN ON REVERSE SIDE) : <br /> RASE <br /> FOR DEPARTMENT USE ONLY <br />' I ` <br /> TPLICATION ACCEPTED BY. <br /> DDITIDNAL COMMENTS: j2 7 DATE <br /> PHASE II GROUT INSPECTION PHASE II/FI AL INSPECTION <br /> NSPECTION BY DATE INSPECTION B —7 <br /> DATE <br /> E HA1426 --74 <br /> Rev. .1 .. 1.(77 �� r <br />