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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF"OFFICE USE: 1601 B. Hazelton Ave. , Stockton, Calif. <br /> �. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued2�� � <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 ~ 2 _ A,-C - (?(+f&V1 0- <br /> CENSUS TRACT <br /> Owner's Name '' 0 f ti Phone <br /> jAddress Ci <br /> I t-� <br />' <br /> Contractor's Name License r, �` <br /> y <br /> TYPE OF WORK (Check) : NEW WELL, /2JDEEPEN '/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION L77`PUMP REPAIR /-7 PUMP REPLACEMENT /7 5 <br /> Other /% 'k' <br /> DISTANCE TO NEAREST: SEPTIC TANK t .EWERL�NES Q T PRIVY j�Zc-V <br /> SEWAGE DISPOSAL FIEL C� f.CESSPOOL/SEEPGE PIT . OTHER qu <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL-7,20 PUBLIC DOMESTIC WELL �-�'^^� Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI $ r <br /> Industrial Cable Tool Dia. of Well Excavation Z33 .w <br /> Domestic/private Dr bed Dia. of Well Casing s •/ CA <br /> Domestic/public Driven. Gauge of Casing !, <br /> Irrigation - - Gravel Gravel Pack Depth of Grout "I <br /> Cathodic Protection J' btary Type of Grout <br /> Disposal Other Other Information 0 <br /> Geophysical rface Seal Installed B l <br /> XN � <br /> PUMP�INSTALLATION: Contractor <br /> -- , __" Type ° <br /> H.P. <br /> PUMP REPLACEMENT: - / / State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> F <br /> DESTRUCTI <br /> ��" "ON 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 /> WEL RILLERS REPORT of the well and notify them before putting the..well in use.. The above <br /> informs n is true to th best of my knowledge and belief. I WILL CALL FOR.A•'GROUT INSPECTION <br /> PRIOR.SO G UTING A� I \INS ION. <br /> SIGNS r� TITLE INC` <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR-DEPARTMENT USE ONLY - <br /> PHASE i <br /> APPLICATION ACCEPTED BY DATE Z U a <br /> ADDITIONAL COMMENTS: <br /> PHA5 T .GItOU INSPECTI N PHASE TIT FINAL INSPECTION <br /> INSPECTION BY <br /> AT <br /> �] .-INSPECTION BY DATE <br /> CA-w <br /> E H 14261-74 1-74� C,�. .Q� f Z /��v►^ <br /> ii f 77 -. ` 2M <br />