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=SAN JOAQUIN LOCAL HEALTH DISTRICT �� ' <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. 74] <br /> 77-/7a-fQ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a-lS=7� <br /> I (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 Joaquir <br /> County Ordinance No. 1862 and the Ruld ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION fir' Q Jr D-figulair.2Z CENSUS TRACT <br /> Owner's Name P�Oh C/U of Phone <br /> : Address D37 City C��QQ4 744/7 <br /> Con'tractor's NameLicense # Phone <br /> c'TYPE OF WORK (Check) : NEW WELL '/1 / DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP:�INSTALATION / / PUMP REPAIR /7/ PUMP REPLACEMENT /_ <br /> 0ther� 5/ v &le . <br /> DISTANCE TO NEAREST: SEPTIC TANK 3` SEWER LINES PIT- PRIVY <br /> { SEWAGE DISPOSAL FIELD f CESSPOOL/SEEPAGE PIT . OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _. CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation 4.1- <br /> r <br /> Domestic/private ! Drilled Dia. of Well Casing [ <br /> Domestic/public Driven Gauge of Casing - \ <br /> Irrigation i Gravel Pack Depth of Grout Seal 4 <br /> Cathodic Protection i Rotary Type of Grout (',Q,��,--_ <br /> Disposal ,! Other Other Information <br /> Geophysical Y Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. l <br /> PUMP REPLACEMENT: � .2�tate;Wor,k_.Done_ _ <br /> . — <br /> PUMP 'REPAIR: / / State Work Done <br /> ' - r . <br /> DESTRUCTION OF WJELL: 411id amete44Wr" \roximate Depth <br /> Describe Material and Procedure o / <br /> .I hereby agree to comply with all laws an.d,-r u' ations o the Sa-- J-daQuin Local�Health District <br /> and the State of California pe VTng to or regulating well 'constr- -'—on:W hin 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROJOING,,WD AlftLNAE1 INSPECTION. <br /> ;SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASA ,I1 G OUT INSPECTION PHA /F NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION. BY r DATEId Iril <br /> g <br /> 1426 Rev. 1-74 <br />