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SAN JOAQUIN LOCAs HE <br /> FOB:OFFICE USE: HEALTH <br /> DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif.- <br /> Telephone:, (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION- <br /> OR PUNT PERMIT <br /> Permit No. 7 6 <br /> THIS PERMIT' EXPIRES 1 YEAR FROM DATE ISSUED _ , ... Date .Issued '1477. <br /> 'Application is:.,hereb made. <br /> + Complete In Triplicate) [ <br /> y to the San Joaquin Local Health District for a.;per ta. co �etrdct <br />; rand/or install the :work -herein described. This application ie made;'. ia-co pliBnce,Olt0 3en,` ]�oaquin <br /> r County Ordinance No. 1862 and the Rule ' and Re Regulations of the..Sect,'Jo, uia� Local_' eatl'`Di <br /> S 4 strict. <br /> JOB ADDRES5/L©CATION 0 <br /> ZDV <br /> 'Owner's$Name ' -�CWPS .TRACE k; <br /> .. <br /> 'Address Phone <br /> .� � � ' <br /> .:City <br /> Coatractor''s Name lv <br /> = � <br /> License # Phone: S'dS <br />_VYPE OF WO (Check D <br /> RK <br /> ). NEW WELL EEPEN �/? RECONDITION <br /> PUMP INS- I7 DESTRUCTION; . <br /> _ALLATION 150 PUMP REPAIR /_J Pip <br /> Other,"Er./ . ' 7" REPLACEMENT � r <br />'DISTANCE TO NEAREST: SEPTIC"TANK <br /> - SEWER LINES PIT'(PRIVY <br /> .. SEWAGEwDISPOSAL FIELD CESSPOOL/SEEPAGE'PIT ' ;" <br /> '. PROPERTY LINE - PRIVATE DOMESTIC WELL:"_,_ PUBLIC-DOME3T (i WELL <br /> _.`� qq s <br /> INTENDED USEV TYPE OF WELL 'N <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> �`�, Cable Tool , Dia. o£ Well Excavation <br /> Diomeatic/private Drilled <br />� Domestic/public Dia. of Well Casing . •�� ; <br /> _: . 'Driven :..r, ' } <br /> Irrigation ' .. Gauge of:Casing , fi <br /> Gravel Pack Depth of Grout-Seal <br /> y Cathodic Protections Rota <br /> Disposal '' > Type of Grout <br /> Geophysical �- Other •-- ,� Other Information }' <br /> Surface Seal-Insealle <br /> x dB � <br /> PUMP INSTALLATION: Contractor ' ' <br /> Type of Pump a <br /> PUMP :; <br /> REPLACE ' <br /> MEIQT� // State Work Done � . <br /> A <br /> PUMP .REPAIR: /-7State Work Done <br />)ES4TRUCTION OF WELL: Well Di <br /> ameCer ' <br />} Describe Material and Procedure Approximate <br /> E hereby agree to comply with.,all'Laws and regulations of the ban'JoagU1h- Local..Health .Distri 't, <br /> Ind the State of California pertaining to or regulating well ''construction;,, o <br /> lifter completion of . ,Within FIFTEEN DAYS <br /> my work on a new well, I will furnish the San: Joaquin Local Health District <br /> FELL DRILLERS REPORT. of. the .well and!notify them before putting-the�.vtell: in.-uset, The': above <br /> formation is true to the best of- my..knowledge and belief, RI WILL CAIli.:FOR A.GROUT: INSPECTiO <br /> IOR TSD GROUTING-AND A FI INSFECTI N <br /> GNED ON. <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> RASE I FOR'DEPARTMENT USE ONLY <br /> PPL'P IL CATION ACCEPTED BY r <br /> DDIT.IONAL COMMENTS: - DATE ' <br /> PHASE 1I GROUT INSPECT ON : <br /> NSPECTIONBY PHASE: III AL INSPECTION <br /> DATE t INSPECTION)$Y ' DATE <br /> E H 1426 Rev. 1-74 <br />