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FOHrOFFIC USEsem, UIN LOCAL`HEALTH DISTRICT <br /> • <br /> �������- 1� � lt'on.Ave., 'Stockton, Calif. <br /> t, el one:-. '{20q) 466-678.1 . <br /> P ICATIO�,fO WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��� <br /> q1 t L6 k� <br /> ����TH�� 'PERM IBES IYEAR, FROM ,DATE :ISSUED ' - y Date Issued <br /> I A iN atiplete In TripZ:icate) ,,-- <br /> f pplicatioa is haxeb eaO�Qt � " <br /> herebyM4 4 5 oaquin: Local..Health, Districi for a' perai�.t to construct <br /> and/or install the wo t�ti'a escribed. . This-a licatlon is .made'.in compliance with Sa <br /> Count Ordinance No. 186s~ PP - n Joaquin <br /> County 2 and the Rules and_Regulations of the :San"Joaquin Local"Health District. I <br /> 20B ADDRESS_ /LOCATION P� " <br /> CENSUS'-TRACT n = r <br /> Owner'.s Name <br /> Address -�, <br /> City . <br /> Contractor's Name <br /> License # -"�� Phone <br /> (e <br /> :TYPE OF WORK (Check): NEW WELL /� <br /> DEEPEN. 7 RECODITION / DESTRUCTIO.` <br /> N <br /> PUMP INSTALLATION / % ,PUMP REPAIR J-7—PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK ' <br /> SEWER LINES PTI' _PRIVY N <br /> '. SEWAGE DISPQSA�L FIELD CESSPOQL/SEEPAGE PiT <br /> PROPERTY LINE - PRIVATE DQMESTIC WELL PUBLZC'DOMESTIHER <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECI�'ICA�ION3�� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> .-Domestic/private Drilled' Dia. of Well Casing �y,i <br /> Domestic/public Driven <br /> X Irrigation Gauge of Casingl�u <br /> Gravel .Pack <br /> .Depth of Grout Sell <br /> Cathodic. Protection Rotary <br /> Disposal �„�� Other <br /> 'e of Grout <br /> Geophysical �._` Other.Information <br /> Surface Seal Installed B n <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , <br /> _ <br /> H.P. <br /> PUMP REPLACEMENT: / / State' Woik Done <br />_U_W REPAIR:R <br /> /„_State ;Work..Done-�­ <br /> ES;TRUCTIQN OF WELL: Well Diameter <br /> Approximate Depth _' <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws- and regulations of ttle San .Ioaquin 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 wall, I will furnish the San Joaquin Local Health District e' i <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 <br /> PRIOR TO GROUTING AND A FINAL INSPEC' IOand belief. I WILL GALL FOR 'A GROUT INSPECTION <br /> SIGNED r <br /> TITLE <br /> {DRAW PLOT PLAN 'ON REVERSE SIDE <br /> PRASE I FOR DEPARTMENT USE ONLY . <br /> { <br /> APPLICATION ACCEPTED 'By­:- <br /> ADDITIONAL <br /> BY.-ADDITIONAL COMMENTS?-21-1/ DATE .3 J <br /> PHASE II GROUT INSPECTION V <br /> INSPECTION BY PHA..$E--III/FINAL FINAL INSPECTION <br /> -DATE INSPECTION $Y s DATE <br /> ,,: Rev 1-74 _ - -. - - . .. . _ . .. _ -. --- '► <br />