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jsit y I SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: ul� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) + 466-6781. U-7.71 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP ,PERMIT Permit No.`zz-ss9Pp#,r <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 /> JOB ADDRESS/LOCATION f�7 i� �2.En�c.! %I y��j f a r CENSUS TRACT + <br /> q2 <br /> Owner's Name Phone L�.z o ��"2 <br /> I Address City <br /> Contractor's Name License #SLL Phoneg S <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT- 1-7Other <br /> DISTANCE TO NEAREST: SEPTIC TANK '-E SEWER LINES PIT PRIVY <br /> SEWAGE DISPOIELD 4• ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELIA��+PUBLIC DOMESTIC WELL <br /> INTENDED USE # TYPE OF WELL A� . CONSTRUCTION SPECIFICATIONS <br /> Industrial � X, Cable Tool 'bia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing^ Z4 `A <br /> Domestic/public Driven Gauge of Casing , ice;, <br /> Irrigations Gravel Pack Depth of Grout' Seal _ U.�,� � <br /> Cathodic Protection Rotary Type of Grout aej A al <br /> Disposal ' ; Other Other Information <br /> l r Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ <br /> 1 Type of Pump - r ,�,.... H.P. <br /> PUMP REPLACEMENT: / / ° State Work Done <br /> PUMP.-.REPAIR: '.�"�"` ./—/State Wo k Done— Q <br /> IDES•1RUCTION 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 /> after completion of my work onla"ii.ew well, IFwill furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the- well and#notify them-before putting the well. in use. The above <br /> iriformation is tiue to 'the. est f., iii�knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A FI SP ON. <br /> SIGNED TITLE ; <br /> JF <br /> ..-` .� '(DRAW PLOT PLAN ON REVERSE SIDE) <br /> �y <br /> F05 DEPARTMENT USE ONLY <br /> PHASE I-- <br /> APPLICATION ACCEPTED SBY • '"4 A ` �' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASEf I GRO T INSPECTION tj AAJ S /FIN INSPECTION <br /> INSPECTION BY <br /> 11 DATE 7- ZI ' 77 INSPECTION BY DATE — - <br /> _ <br /> 7/Z 617 1 1 12M <br /> E H ,1426 Rev. I-74 <br />