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-"� SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> s Calif. <br /> Stockton <br /> SDH OFFICE USE: 1601 E. Hazelton Ave. , 7 ���� 1' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WE Permit OR PUMP PERMIT Permit <br /> THIS <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued <br /> t <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 <br /> ulationsapplication <br /> the Sanmade <br /> JoaquinpLoe lHealth <br /> eSan <br /> District. <br /> County Ordinance No. 1862 and the Rules and R g <br /> r, CENSUS TRACT <br /> JOB ADDRESS/� } <br /> � Phone <br /> Owners Name <br /> City <br />. Address <br /> License Phone <br /> i Contractor's Name Mnn 1'I S <br /> r�/ d v <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION f / DESTRUCTION /7 <br /> INSTLATION / PUMP REPAIR / / PUMP REPLACEMENT I�T <br /> k aOther /; � <br /> DISTANCE TO NEAREST: SEPTIC TANK ©-SEWER LINES _ -- PIT PRIVY <br /> SEWAGE DISPOSALLD �r CESSPOOL/SEEPAGE PIT��I�TR <br /> PROPERTY LINES RIVATE DOMESTIC WELL Z!2,-�-�TUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL a CONSTRUCTION- SPECIFICATIONS W <br /> Industrial Cable Tool Dia, of Well Excavation 7777, <br /> j Domestic/private T- Drilled Dia. of Well Casing-_ Jr 1 <br /> Domestic/public Driven Gauge of Casing <br /> Gravel Pack Depth of Grout <br /> Irrigation Seal <br /> Type of Grout l�;,E <br /> Cathodic Protection <br /> Disposal Other Rotary f Other Information <br /> ------ <br /> Geophysical ' Surface Seal Installed B <br /> PUMP INSTALLATION: ontractor, H.P. <br /> Type of Pump Sf - <br /> PUMP REPLACEMENT: ' / / State Work Done ` j <br /> PUMP .REPAIR: / State Work Done --- --- <br /> ` —Approximate Depth <br /> DES-TRUCTION OF WELL: Well Diameter +` w <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 we'1'1'construction. Within .-FIFTEEN DAYS <br /> -�----- �'__ q. <br /> { after completion of--*—Work on a new well, 17111 furnish tha San Joa uin Local�Health District a <br /> WELL DRILLERS REPORT--of-. the well and notify them before putting-the-well in use.,,' The above <br /> information is true to the best of my knowledge and belief I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. //�5 <br /> �{� _ -TITL � <br /> SIGNER <br /> DRAW' B T' FLAN ON .RE RAE 5 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> It L-1 <br /> ADDITIONAL COMMENTS: PHAS I I/ NAI, INSPECTION or' <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> K--H- 1426----Rev. 1-74 <br />