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Y�y SAN JOAQJIN 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. %C- <br /> c�S1 1� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7 <br /> 7Y- <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 Joaquii: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /Jl f &Tp / CENSUS TRACT <br /> Owner's Name /�C�' / J ,rA Phone,3��- �d <br /> Address ` '*rp+ 4e. City <��-Wo< <br /> Contractor's Nameoe_pa�<11!�_ ; Ii01'z _ License Phone <br /> TYPE <br /> TYPE OF WORK (Check) : NEW WELL /_/DEEPEN RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION UMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT BOTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 146 <br /> Type of Pump v H.P. _3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT the well and notify them before putting the well use. The above <br /> information is tr to the best i; W <br /> owledge and belief. I WILL R A GRO INSPECTION <br /> PRIOR TO N I <br /> SIGNED d TITL <br /> RAW PLOT PLAN ON REVERSE SIDE) / <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY /¢ 7 Y f e�X 1/11tt�t A DATE <br /> ADDITIONAL COMMENTS: ��� <br /> PHASE II GR T IN PE ON PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />