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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.J <br /> r . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S 31 77. <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 /> 1 JOB ADDRESS/LOCATION - �(,�� �Uy��, ,7Z3 CENSUS TRACT <br /> r <br /> Owner's Name' <br /> _ E Phone <br /> Address <br /> City �Dzq/ C44 <br /> Contractor's Name 11f / License # / Phone 9- 72 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION f? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE IDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I Industrial Cable Tool Dia. of Well Excavation ___0 i <br /> SDC Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation g � Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of GroutIL Disposal 1 Other Other Information <br /> Geophysical ( Surf ace Seal Installed <br /> PUMP INSTALLATION: Contractor t,44 l <br /> Type of PumPJ/�/Y/� .,...._.:.,..—_,.__.— H.P. j- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done- <br /> DESTRUCTION OF WELL,: We11 Diame.tar--- 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 we11`:'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish 'the Joaquin"Local Health District a <br /> WELL`%DRILLERS REPORT of the well and notify them before putting. the w+.�ell.._in_us.e..,.,.,:The above <br /> information is true to the.best of my knowledge and belief. I' WxLL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D A FIN SPECT ION. <br /> SIGNED TITLE <br /> t (DRAW 11LOT PLAN ON REVERSE SIDE), <br /> + FOR DEPARTMENT USE ONLY <br /> E PHASE I <br /> APPLICATION ACCEPTED BY _ DATE L3 .? <br />'i ADDITIONAL COMMENTS: - <br /> PHASE II CROUT INSPECTION HA5 AL I/F-I INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE <br /> ZKl <br /> E .H• 1 26 Rev. 1-74 376 2M <br />�, . 4 <br />