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SAN,.JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE:_ 1601­ E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, '7 <br /> - THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7� <br /> { k� (Complete In Triplicate) <br /> Application is tereby 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 N.o-.-1862-.and. the-.Rules and Regulations of the San Joaquin Local Health District. <br /> k JOB ADDRESS OC . qC7 CENSUS TRACT 01 Z-OV f0 --I/ <br /> Owner's Name r Phone <br /> f ~. <br /> Address <br /> City ` <br /> f Contractor's NameLicense # 1 Phone; - � <br /> .- TYPE OF WORK (Check) : NEW WELL /VDEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 - <br /> Otherf/ / <br /> f � O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE `DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL RTf' <br /> •-- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA IONS ?: <br /> Industrial <br /> _ able Tool' ,', Dia.- of�We].l Excavation <br /> r Domestic/private Drilled �� ` "�' 41 1."K � '-` <br /> < -. _ Dia;:{off We11CaSing,a� .. .. ._�_,..'........��, .. . _� <br /> ' <br /> Domes t i c -4...,-.--�..�........�.�. .._.-._....,.c,.. <br /> /publics DrivenGauge, of Casing- <br /> rrigation Gravel Pack Depth of,Grodt S'eal' ' " <br /> fCathodic Protection Rotary T <br /> f ype°,ofGr <br /> Other,. <br /> Disposal 1. 1 1,,Other I,nfor.mation'� <br /> _-Geo�phy,--sical + f <br /> E Surf ace, S al`Ins tailed B : ' <br /> PUMP INSTA LATION: Contractor' <br /> F TYPe of Pump H:p.#T. <br /> t PUMP <br /> REPLACEMENT: <br /> k <br /> /_7 State Work Done , <br /> -PUMP •.REPAIR.: � � i } <br /> State Work Done <br /> t <br /> r <br /> DESTRUCTION OF WELL; Well Lmeter Approximate Depth <br /> p <br /> r�r Describe Material and Procedure <br /> ' I hereby agree to comply with all laws and regulations of the San, Joaquin Local Health istrict <br /> . and the State of California pertaining to on regulating well ',construction, Within FIFTEEN DAYS <br /> after completion of my�,worlN on a new well, I. will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of*othe"wFelk and notify them before putting the well in use. The above <br /> ' information is true to_th�e`�best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION E <br /> .PRIOR TO G OUTING AND ,A-.. INAL. INSPECTION <br /> SIGNED TITLE + r <br /> ".' ( (DRAW PLOT PLAN ON REVERSE SIDE) <br /> `PHASE I FOR DEPARTMENT USE ONLY <br /> i APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> 1 PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION. <br /> INSPECTION BY DATE INSPECTION BY DATE //'•31'77 ' <br /> E H 1426 Rev. 1-74 J _ 11.x77 2m <br />