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SAN JOAQUIN LOCAL HEALTH DISTRICTS <br /> FOE tOFFICFt USE: " 16G1.4E... Hazelton Aver; Stockton,—Calif. <br /> Telephone-: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. t <br /> / THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,7d <br /> (Complete In Triplicate) <br /> 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 iii compliance with San Joaquin <br /> County Ordinance No. 1862 grid the Rifles and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �d�S��/" �fe �j"� !�" Gsta� B CENSUS TRACT <br /> Owner's,Name /tip f�Y�' Phone <br /> �` �../ ACity r. , <br /> Address � -_,-,� � <br /> Contractor's Name License #/ 21- Phone w p <br /> _ a <br /> TYPE OF WORK (Check) : NEW' WELL /? DEEPEN '/ RECONDITION /? DESTRUCTION /-7 , <br /> PUMP INSTALLATION Ig PUMP REPAIR/ / PUMP REPLACEMENT <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 ML # <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 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other information <br /> Geophysical Surface Seal` Installed By:--'m <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump tie 2] ..0 H.11. <br /> PUMP REPLACEMENT: / / State Work Done - - <br /> PUMP .REPAIR: / / - 'State Work Done _ <br /> DESTRUCTION DF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withall laws and regulations of the" San Joaquin Local Health Hlstric <br /> and the State of California pertaining to or regulatingmwell`construction. Within FIFTEM 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 ato've <br /> information'is -.true to t'he beet of- my-knowledge and belief, I .WILL CALL FOR A GROUT I9SPECTICk <br /> PRIOR TO"4EUTIRd"AND A FINAL INS I - <br /> SIGNED; TLE.. (► <br /> W ON FRSE SIDE : - ---. ' `i <br /> J)EPARTMNNT USE ONLY <br /> PHASE 1 <br /> APPLICATION ACCEPT N:&LF DATE / .. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IISPECTION PHASE III FINAL INSPECTION' <br /> INSPECTION BY DATE INSPECTION BY DATE / IL/ 7 . . <br /> i I 3V76 Mr <br /> L H 1426 Rev. 1«74 <br />