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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 peY�t No. -= J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> ued 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM Iss <br /> DATE ISSUED- Date L -� <br /> (Complete In Triplicate) 7�0,1 `cOLl-( (D <br /> Application is hereby made to the San Joaquin Local <br /> application <br /> pplicat nDistmade inrco pli�eetwithconstruct <br /> Joaquin <br />` and/or install the work herein described. This app <br /> County Ordinance No. ..1862`and the Rules and Regulations of the-San JoaquI. in Local Health District. <br /> ^). -ttcuti� � RACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name 4 <br /> City S4 - <br /> Address �`T <br /> x censejq '� Phon �Z <br /> Contractor's Name <br /> r <br /> TYPE OF WORK (Check) ; NEW WELL /L-f--DEEPEN / RECONDITION /7 EPUMP REPLACEMENT UCTION <br /> IIT <br /> PUMP INSTALLATION I I PUMP REPAIR / I <br /> Other [-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER.,LINES PIT PRIVY <br /> iR <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER'_ <br /> PROPERTY LINE - PRIVATE DOMESTICLLrRNSTIC �ELL <br /> STR CTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial L—Mle Tool Dia. of4Well' Excavation !rl <br /> led Dia.,of Well Casing <br /> Domestic/private Dril <br /> Domestic/public Driven Gauge of Casing ! D <br /> fGravel pack Depthaof Grout Seal I` <br /> Irrigation ,E <br /> Cathodic Protection Rotary Type of Grout <br /> Other Other Information ' <br /> Disposal <br /> i Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump 4. <br /> " PUMP REPLACEMENT: / / State Work Done <br /> .PUMP .REPAIR: , <br /> State Work Done­ <br /> Approximate <br /> . ) Approximate Depth <br /> DES:TRUCTION OF WELL: Well Diameter <br /> F <br /> Describe Material and Procedure <br /> f k � <br /> I he,reby 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 /> iafter Completion a£ my work on a new well, i will furnish the .San Joaquin Local Health District 2 <br /> f tting the well in use. The above <br /> WELL DRILLERS REPORT of the well and notify them before pu <br /> information is true to the best of my knowledge and belief. I WILL CAI; . FOR A GROUT INSPECTION <br /> PRIOR TO GRO IN AND A FINAL INSPUTION.. ' . TITLE <br /> SIGNED :s1 <br /> DRAW PL T' PLAN '4N REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE IDATE l_Z1 <br /> APPLICATION ACCEPTED BY Q <br /> ADDITIONAL COW=S: pHASE,III/FINAL INSPECTI N�1 <br /> TjkSE II GROUT INSPECTION INSPECTION 'BY J DATE It.OZ <br /> INSPECTION BY DATE f; <br /> 3/76 2M . <br /> E H 1426 F:ev. 1-74 _ <br />