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SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'Zeljal�6,fl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> t <br /> JOB ADDRESS/LOCATION } CENSUS TRACT,- <br /> Owner's <br /> RACT `Owner's Name <br /> Address City <br /> Contractor's Name , ` ` � License # 09D�/�Phone <br /> _. <br /> TYPE OF WORK (Check) :1 NEW WELL DEEPEN /_/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / / <br /> 7� Other i/ / <br /> t <br /> DISTANCE TO NEAREST.:' SEPTIC. TANKEWER LINES PIT PRIVY _ <br /> ! SEWAGEtDISP601UD 1je* CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL ______ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> ✓ Domestic/private Oil�� Drilled Dia, of Well Casing b <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation # Gravel Pack Depth of Grout Seal <br /> Cathodic Protection '- Z Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical [ Surface Seal Installed By: 17 <br /> PUMP INSTALLATION: Contractor <br /> }Type_. .f_Pump. H.P. <br /> PUMP REPLACEMENT: / ,/ StatetWork Done {�- -- — -- - _ <br /> F E <br />���, -.•_.fir. .. �r.r-_ __ - .- '--•,-., . � .-, -. �..-�3._��.--.G�: v�^x_ -�-- � ^-��`...Y....r-r � :.-,��y��r== -. ._ ,r - _- <br /> PUMP .REPAIR: = - /�-/�•State--Work Done <br /> ,� N <br /> DESTRUCTION OFWELL: Well Diameter ., <br /> --, ,,; ('-,Approximate D'e'pth <br /> De'scribe' Material and Procedure i 'J i. <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'constructiori. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I wi11 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 above <br /> information is true .to the best of my knowledge and belief:' I WILL CALL7F0R.A GROUT INSPECTION <br /> PRIOR TO GO TING ANDA INSPECTION:"'""` <br /> SIGNED ' ^ . <br /> TITLE A <br /> (D LOT PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br />' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAU II GROUT INSPSCTION PHAS I/F NAL INSPECTION <br /> INSPECTION BY DATE '57-- INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 b/77 _ M <br />