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4 Gd- SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> F0 OFFICE USE:- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> a APPLICATION FOR"WEI;L'-'CONStRUCTION OR PUMP PERMIT Permit0o.-t <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 Joaquini <br /> County Ordinance No. 1862 an the ules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/I.CATION CENSUS TRACT ' <br /> aiat <br /> Owner's Name._-" Phone �p <br /> Address 4MCity i <br /> Contractor's Name c License # A2hone <br /> TYPE OF WORK (Check) : NEW WELL/-7 'DEEPEN /7 RECONDITION /-7 DESTRUCTION w <br /> PUMP INSTALLATION-/_`/ PUMP REPAIR / / PUMP REPLACEMENT f� w <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 SPECIFICATTIONS <br /> Industrial Cable Tool Dia. of Well Excavation— <br /> Domestic/private Drilled Dia. of Well Casing 'L" x I O"�i,u►e�r" , <br /> Domestic/public, Driven Gauge of CasingIrrigation Gravel Gravel Pack Depth of Grout Seal -_ <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal Other Other Information -� <br /> Geophysical Surface Seal InstalledoBy: <br /> - <br /> PUMP INSTALLATION; Contractor ..` <br /> Type of Pump. H.P. <br /> PUMP REPLACEMENT: - ' State'°,Wolf,DaneIj <br /> +_- -- -- -- <br />-PUMP-REPAIR: -/—/—State-Work Done----- :; _ — x - ._. <br /> DESTRUCTION OF WELL: Well Diameter u j e Approximate Depth <br /> Describe Material and Procedure <br /> r1 '� <br /> I,.hereby agree to comply with all laws a=id regulations ;Vt5e­S7n--J6raa4uin Local Health District N <br /> and the State of California pertaining to or regulating well'construction. Within FIF'TtIN DAYS <br /> after completion a work on a ne 11, I will furnish the San Joaquin Local Health District a I <br /> WELL DRILLERS REPORT f the well d n y them before putting thewe3.1 in use. The abdve' <br /> information is- true he <br /> A". <br /> wledge and belief. I WILL CALL FOR A GROUT Ii�SPECTIQN..PRIOR G UTI G FI <br /> SIGNS TITLE <br /> h�•r�,', <br /> D W' � PLAN ON RSE SIDE <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 'APPLICATION ACCEPTED BY f DATE <br /> ADDITIONAL CONHENTS: <br /> PHASE II GROJT IIQSPECTION PHASE III FTNAI. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE,-77 <br /> 3/76 2K <br /> E H 1416 Rev. 1,74 , <br />