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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.lf_31, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 VeCENSUS TRACT <br /> Owner's Name ��, \ \��- Phone <br /> Address ��C�qy � 5``.�_ P City ';;7S c4k Lit, <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL Jt/ DEEPEN /`RECONDITION CIT DESTRUCTION %j C�j <br /> PUMP INSTALLATION/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK s SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD 5l-- CESSPOOL/SEEPAGE PIT - OTHER -- <br /> PROPERTY LINE_ PRIVATE:DOMESTICtWELL _ ,PUBLIC DOMESTIC WEL!� <br /> INTENDED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool < 4DLa. of Well. Excavation <br /> Domestic/private Drilled Dia, of WelliCasing_ <br /> Domestic/public Driven Gaugefof`Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i 12 77,� <br /> Cathodic Protection Rotary Type of- Grout! <br /> Disposal r� ' Other ✓ Other._Information r i <br /> Ceo.physical Surface Seal Installed By:. i <br /> PUMPI.INSTALLATION: Contractor �^ t <br /> Type o`f Pump - y_ H.P. <br /> PU,NP_REPLACEMENT_:.: / / State Work Done ~` ' <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION 'OF'WELL: Well Diameter ! �~� Approximate Depth ' <br /> Describe Mate al 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 per-taining-to_orJregulatixig_well'construction. Within FIFTERN DAYS <br /> after completion ofmywork on a new well, I will furnish the San Joaquin Local Healtht. Districa <br /> WELL D%G' <br /> S REPORT of the�well#ai�i k6ti€y .t"hem' before putting the .well in use. The abdve" " <br /> informis.-true t h my"knowledge and belief. I WILL CALL FORA GROUT INSPECTION - <br /> 'Rn <br /> PRIOR UTING AND E <br /> SIGNE r " (�:' TITLE <br /> D W"'PWT PLAN 'ON UffkSE SIDE <br /> FOR DEPART USE ONLY <br /> PHASE I <br /> APPLICATION 'ACCEPTED BY c1\' DATE <br /> ADDITIONAL iMMM MTS: <br /> PHASE II G iEQSPECTTON P SE FINNK INSPECTION! <br /> INSPECTION BY DATE3 INSPECTION BY DATE 5--13- <br /> 7 <br /> Bev. 1-74 <br /> B g 1426 _ <br />