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` SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 14 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' Date Issued ,�77 <br /> Application is hereby made to the San (Complete Joaquin <br /> LocalTriplicate) <br /> 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 eq &6 -7 5 t <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone �`•, <br /> Address ,4 P-n <br /> City ,,] <br /> Contractor's Name : <br /> ' License #,;2 Phone 4.7 <br /> TYPE OF WORK-,-(Check) : NEW WELL/_7 DEEPEN / / RECONDITION /7 DESTRUCTION /7 l <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT- 1-7 ` <br /> Other / / -- <br /> r <br /> d, <br /> DISTANCE TO NEAREST: SEPTIC TANK , . SEWER LINES PIT PRIVY <br /> ti SEWAGE DIS-POSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY�LIIVE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL�� <br /> INTENDED USE TYPE OF WELL <br /> Indus CONSTRUCTION SPECIFICATIONS ` <br /> ural ---- ---CaB-Z�T� �- —DjTa-- Well E �avatibn <br /> Dome s.t 1c./privatP_ � gilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing i \\ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathod d:., Proteetj,pn .� 4' Rotary <br /> Disposa-1. Type of Grout � <br /> Other Other Information <br /> Geophysical `~ • ° �% <br /> Surface Seal Installed-B : <br /> PUMP INSTALLATION: Contractor.- <br /> TYP. of'P, <br /> .e <br /> ' H.P. <br />'UMP REPLACEMENT: . / / State Work Done ; <br />?UMP -.REPAIR: State Work Done <br /> LES•TRUCTION OF WELL: Well Diameter ' <br /> Describe Material and Procedure Approximate Depti <br /> hereby agree to comply with all Yaws and regulations of the. San Joaquin Local Health District <br /> end the State of California pertaining to or regulating well "construction. `Wit3rin-­F!-FTERN--DAYS <br />.fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the .well. in use. The above <br /> nformation is true to the best of .my knowledge and belief. I WILL CALL FOR A GROUT%INSPECTION <br /> RZOR TO GRO ING AND A INAL INSPECTION. <br /> IGNED TITLE 3 . <br /> (DRAW PLOT PLAN ON REVERSE SIDAf <br /> VASE I E` t FOR DEPARTMENT USE ONLY . <br /> �s <br /> PPLICATION `ACCEPTED 5'BY F, DATE <br /> DDITIONAL COMMENTS: <br /> PHASE�II OUT`INSPECTION PHAS II IN ,r INSPECTI N ' <br /> NSPECT ION BY ,• DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1/�Z7: _ " 2M <br />