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Hyl/ 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. 7,6- 9�pp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a_.Y_ 7-6' <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 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 ` S <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 1� <br /> city �r�c <br /> Contractor's Name License # ��Z,3 one ]]Is <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / 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 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> xrdustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing r^ <br /> Domestic/public Driven Gauge of Casing E <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: , State Work Done <br /> PUMP-;REPAIR:,. ,F z ._ +/ 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 Staifornia pertaining to or regulating well'-construction. Within\ FIFTEEN DANS <br /> after co, Wl�Ationofwork on a ne 11 I willfurnish the San Joaquin Local Health District a <br /> WELL DR f the well d f them before putting the..well in use. The above <br /> infor tiothe. es f o edge and belief. I WILL CALL INSPECTION <br /> PRIOR TO GA F <br /> SIGNE TITLE <br /> ., D _- P PLAN 'ON rtSE SIDE 11.'.' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 7 <br /> ADDITIONAL 4COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE T <br /> E H 1426 Rev. 1774 ` . <br /> 3/76 �;:: . <br />