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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 'OFFICE"USEr 1601-E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : {20�J. 466-6781 <br /> APPLICATION FOR WELL 6NSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES-1 YEAR FROM DATE ISSUED Date Issued ,2 <br /> (Complete In-..Triplicate) <br /> E Application is hereby made 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 and the Rules and Regulations of the San Joaquin Local Health District. 4, <br /> JOB ADDRESS/LOCATION I/I)6 ,Q� � / rd�l��c P CENSUS TRACT <br /> �. g <br /> Owner!.s Name r2 L. �` Phone ���-,�•�c) <br /> Address'' //�y �' C city _C go, <br /> Contractor's Name e� rLicense #,,,9 FoDPhone <br /> TYPE OF WORK (Check) . NEW-WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> t PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / �Jl <br /> DISTANCE TO NEAREST-:a- SEPTIC TANK /$-Q ` SEWER LINES PIT PRIVY ~' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT L, _D OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL a' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation d2 X <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout �,e,•,P,u�' <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: _A '1. G,ej_V s <br /> PUMP INSTALLATION: Contractor _(.L r-e - <br /> Type of Pump 4� �-- - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 State of California pertaining to or regulating weil•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 CALL FOR_A_ G.RO.UT_IN,5.PECTJION <br /> PRIOR TO GROUTINE AND A FINAL NSP N-. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE 72. <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT -TINSPECTION PHASE III/FINAL INSPECTION ' <br /> INSPECTION-BY—'_T!: '""" "*DATE= <br /> ,177 . 2M <br /> E H 1426 RPv- 1-74 t <br />