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T G <br /> , SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70B4OFFICE USE: U 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _, Telephone: (209) 466-6781 F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> /THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to, the Sun Joaquin Local Health District for a permit to ,cr:nstruct <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 Heal.th.District, <br /> JOB ADDRESS/LOCATION Zqae!�7 <br /> CENSUS TRACT <br /> Owner t s Name 4 PhoneAT <br /> Address Cityr {� <br /> Contractor's Name -�� � r icens 'M Phony. # <br /> � 21. E <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ RECONDITION f DESTRUCTION /� <br /> PUMP INSTALLATION ' S REPAIR/-7 PUMP'¢REPLACEMENT <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD- - - „CESSPOOL/SEEPAGE PIT. r OTHER � \� <br /> *-PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC'.DOMESTIC WELL <br /> INTENDED USE^- TYPE OF WELL CONSTRUCTION .SPECIFICATIONS <br /> Industrialr.` 3 t----Cable Tool Dia, of Well Excavation <br /> 1----ffbmestic/private Drilled Dia. of Well, Casipg. ,. <br /> Domestic/public Driven Gauge of Casing_.,, !d .. <br /> I� <br /> - Irrigation � r/ Gravel Pack Depth of°Grout Seal: `0 <br /> Cathodic Protection Rotary E Type ofkGrout a <br /> n <br />' Disposal. -? Other." <br /> ther i r Other Information , <br /> Geophysical �•Surface'Sea1 Installed B <br /> s <br /> PUMP INSTALLATION; . Contractor <br /> Type of Pump , ---=w- H.P: <br /> PUMP REPLACEMENT: `. /-7 State Work Bone ��'� <br /> PUMP '.REPAIR: / / 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 State of California pertaining to or regulating .well-'construction.., Within FIFTEEN DAYS <br /> i after completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> r WELL..DRILLERS REPORT of the well and notify them before putting. the..well. in.use.... The above E <br />( information is true to the-best.of- my%knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FIN& INSPWNON. <br /> 01 <br /> SIGNED _ TITLE - - _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE). n <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> f APPLICATION ACCEPTED BY DATEZZZ-6 <br /> ADDITIONAL COMMENTS: <br /> PHA E II G OUT INSPECTION PHAS&IIF NAL INSPECTIQN <br /> : INSPECTION BY DATE INSPECTION BY DATE <br /> '- E H 1426 Rper_ 1-74 r h/75.._. 2M _ <br />