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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOS ,OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 91 1P <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued to-zp,7K <br /> (Complete In Triplicate) , <br /> Application is hereby made tolthe 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. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address d <br /> � city Z_11�'�m�. <br /> Contractor's Name License # Zy3-9,2,C-Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / -DEEPEN. / / -RECONDITION / / DESTRUCTION /_7 F <br /> PUMP INSTALLATION`](/—PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other ./ l — <br /> DISTANCE TO -NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> a <br /> SEWAGE DISPOSAL FIELD CESSPOOQSEEPAGE PIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing Q <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of <br /> Pump , E, H.P. <br /> PUMP / / State Wotk Done /1/W6++�.� �+ I <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION ,OF WELL: Well Diameter Approximate Depth <br /> �® Describe Material and Procedure <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local Health District <br /> and -the State of .,California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> afte.r. '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 s <br /> information is true to the beat oowled d belief. I WILL CALL FOR A GROUT INSPECTI6N <br /> PRIOR TO O. TING AND A FIN P N. <br /> SIGNED TITLE <br /> D W PLAN"'ONA4VRRSE SIDE) <br /> FOR DEPARTMENT USE ONLY ; M1 <br /> PHASE I f <br /> APPLICATION ACCEPTED BY DATE /d7 <br /> ADDITIONAL COMMENTS: "• <br /> PHASE II GROUT INSPECTION .. PHASE III FINAL .INSPECTION <br />�TNSPECTION BY DATE INSPECTION BY DAT-E 10-- <br /> E H`1426 Rev. 1--74 3/76 2M <br /> = a k <br />