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SAN JOAQUIN_LOCAL HEALTH DISTRICT AJ�t <br /> FOFK OFFICE USE: 1601 E. Hazel&-027 Ave. , Stockton, Calif. <br /> Telephone : " (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ__0A_s/_4J <br /> THIS] <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-/A!77 t <br /> 11 (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 hereinldescribed. 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 NSUS TRACT� r �- <br /> Owner's Name (^ Phone 6 <br /> A <br /> Address, City42� <br /> Contractor's Name <br /> ` License # Phone <br /> a, <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN%/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / /� i PiJMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: `SEPTIC TANK _ � SEWER LINES !f5'-4- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> %!PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE i " -,T-YPE!OF WELL CONSTRUCTION SPECIFICATIONS �.]# <br /> Industrial ' -T —Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drifted Dia; of Well. Casing <br /> Domestic/public ."r 1 t I D.ri�en� Gauge of Casing _ <br /> ' G .:.�, -o-f <br /> �Ir_rigat on_K�- •. C ave3 °ack--- = Depth � <br /> Cathodic Protection , kotary��� ' Type of Grout . [ L, <br /> Disposal I ;Other Other Information � a- <br /> Geophysical Surface Seal Installed B F,,+ <br /> PUMP INSTALLATION: Contractor r� S <br /> Type of Pump .. H.P. <br /> PUMP REPLACEMENT: T �"�/`$/ S to-te-Work Done <br /> s <br /> PUMP .REPAIR: / / State Work Done , <br /> DES:TRUC IOT NOF"WELL: Well Diameter Approximate Depth <br /> �f Desc :Cbe Ma erial and rocedure ri <br /> IM4ereby agree to comply kith all. laws nd regulaiio `of the S Joaquin L cal Health District <br /> and.the State California pertaining to or regulating well construction. Within FIFTEEN DAYS r <br /> after completion 0 m work on a new well, I will furnish the San Joaquin Local Health District a <br /> WEhL 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 GROUT INSPECTION <br /> i <br /> i <br /> PRIOR' TO GRO TING AN INAL SP C ION. TITLE <br />•SIGNED9 / T iC <br /> ( W PL T PLAN ON RVERSE SIDE) <br /> t <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTIO PHA III/, IN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �� t <br /> { / tel`c.r r� <br /> 1177 . .-. 2M <br /> E H 1426 Rev. 1-74 � <br />