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t. �. SAN JOAQUIN LOCAL. HEALTH DISTRICT { <br /> F .',OFFICE USE: * 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 ,7 � XV) <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. / y <br /> r� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, <br /> t )6' (Complete In Triplicate) <br /> Application is tereby 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 /> 3 CENSUS TRACT _ <br /> JOB ADDRESS/LOCATION <br /> LO�/E T c E Ad J Phone <br /> Owner's Name <br /> City F v <br /> Address AIX ZZr 10" <br /> 621, <br /> Contractor's Name <br /> License j�/ 2�/ Phone" <br /> -r 'POW <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 'RECONDITION' RECONDITION DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEME <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1� <br /> Industrial g Cable Tool Dia. of Well Excavation � <br /> Domestic/private Drilled Dia. of.Well Casing + \^ <br /> Domestic/public Driven Gauge of Casing - A <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ d Surface Seal-Installed By. <br /> "amu~rd' INSTALLATION: Contractor <br /> H.P. ' <br /> Type of Pump <br /> SMP REPLACEMENT: / / State Work Done <br /> PUMi ,.REPAIR: / / State Work Done <br /> Approximate Depth <br /> DEST.,RUCTION OF WELL: Well Diameter --- <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in-use. The above <br /> information is true toa es o my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO N AND F ECT ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> IDEPART14ENT USE ONLY <br /> PHASE I j W7171 DATE - 23.` <br /> APPLICATION ACC <br /> ADDITIONAL COMMENTS: PHAS I/FIN INSPECTION <br /> PHASE II GROUT INSPECTION DATE r <br /> INSPECTION BY DATE ECTION BY ` <br /> t - ! 1/77 <br /> F u IA26 Rav_ 1-74 <br />