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i ;I F""T' JOAQUIN LOCAL HEALTH. DISTRICT <br /> [Ck OFFICE USE.: it 160 Hazelton Ave. , Stockton, Ca <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> 4 <br /> 111THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ff (Complete In Triplicate) "I <br /> 3plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of t e San Joaquin ;Local Health District. <br /> )B ADDRESS/LOCATION l7 sCJ ��� z � CENSUS TRACT <br /> - i <br /> rner r s Name �` ,� Phone , -� <br /> !dress �/ -� � City <br /> .3ntractor's Name License #.VV GFlE3 Phone S JJ�f <br /> . 1 <br /> fPE OF WORK (Check) : NEW WELL/ DEEPEN %/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTDATION /. / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> ISTANCE TO NEAREST: SEPTdIC TANK SEWER LINES ;! PIT PRIVY <br /> 1 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT s OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE i1 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> F, <br /> Industrial Cable Tool Dia, of Well Excavation;I 5z } , <br /> L--Domestic/private 'Drilled Dia. of Well Casing �v j <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation r� Gravel Pack Depth, oWo-eR <br /> out Seal <br /> Cathodic Protection, z--Rotary Type of <br /> Disposal Other Other Information ,E <br /> Geophysical i� Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor �, r <br /> _ - Type of Pump . H.P. <br /> IMP REPLACEMENT: / % State Work Done <br /> UMP .REPAIR: / % State Work Done Ji <br /> ES.TRUCTION OF WELL Well Diaiueter Approximate Depth <br /> Des' cr•be Materi 1 and Procedure s <br /> hereby agree to com with all laws and regulations of the S n Joaquin Lo Health District j <br /> nd the State,of Califoor a"per-ta-ini-ngx-t.o.-o .egulatiag.,,W.ell=::construction. Within FIFTEEN DAYS <br /> iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION- <br /> RIOR TO G OUTING A FINAL INSPECTION. <br /> SIGNED TITLE - <br /> li (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ' ASE I <br /> iPPLICATION ACCEPTED BY A2 ' DATE -77 <br /> ADDITIONAL COMMENTS. <br /> PHASE GROU rINSPECT10N PHAV III/FINAL INSPECTIO <br /> �:NSPECTION INSPECTION BY DATE l0 J <br /> F }1 1G26 1Z.- -71i rev <br />