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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOElOFFiCE t1SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z-S�V 4l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue(?� - j <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 <br /> CENSUS TRACT <br /> Owner's Name Phone 5�fI_ Ido <br /> Y <br /> Address •� --F CityC�Wie6f\_(, <br /> Contractor's Name ip <br /> cense Phone ..�' <br /> f <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN '17 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / REPAIR /_7 PUMP REPLACEMENT f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ' <br /> EWER LIES IT PRIVY <br /> # SEWAGE DISPO AL FIELD ��'^CESSPOOL/SEEPAGE PIT h OTHER <br /> {` PROPERTY LINE - PRIVATE DOMESTIC WELL'; PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF'WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool Dia. of Well Excavation �t <br /> omestic/private Drilled- Dia. .of Wel] Casing 1 <br /> Domestic/public Driven ` Gauge o Casing <br /> 1 <br /> Irrigation g G�r vel Pack Depth of'Grout Se <br /> Cathodic Protection 4-- otary Type of Grout,l <br /> ;Disposal - Other 'Other Informatio ' <br />-Geophysical ��'. <br /> Surf . Seal Installed By. r <br /> PUMP INSTALLATION: Contractor + ' <br /> Type of Pu *� <br /> PUMP REPLACEMEState Work ;Done' '+ ; <br /> PUMP REPAIR: /? State Workl"Done <br /> ,, <br /> STRUCTION OF WEL : Well Diameter <br /> Approximate Depth _ G j <br /> Describe Mater-ial.and-P educe <br /> al- <br /> I hereby, agre2'to comply with all Ms and regulations of the San .Jo, qui Local Health District <br /> and the State of California pertaining to or regulating well construction. Within'FIFTEEN DAYS <br /> after completion of my work on a new well, I will 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 /> info on is true to the wl dge and belief. I WILL CALL FORA GROUT INSPECTION <br />?RiOR TING AND A FIN i N <br /> SIGNED <br /> TITLE <br /> LOT PLAN ON REVERSE SIDE <br /> 'FOR DEPARTMENT USE ONLY <br /> PHA <br /> APPLICATIO CCEPTED BY �C DATE <br /> ADDITIONAL COMMENTS: <br /> P • I GR INSPECTION. . ' P II FI AL INSPECT <br /> INSPECTION BY DATE - INSPECTION BY <br /> DATEF;A� <br /> E H 1426 Rev:--1-74 jr <br /> T-74 9M <br />