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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> +J' 1601 E. Hazelton Ave. , Stockton, Calif. f <br /> � <br /> 466-6781 D td <br /> FOB'iOFF �USE. Telephone: (209) PERMIT Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP <br /> Date issued �� <br /> IS PERMIT EXPIRES 1 YEAR <br /> FROM DATE ISSUED F <br /> (Complete ir► Triplicate) ermit to construct <br /> San Joaquin Local Health District for compliance with Sall Joaquin <br /> Application is he by made to the application is trade in mp <br /> and/or install: the word herein described. This app oa 2-co-(I <br /> 62 and t Rules and Regulations of the 3oaquin Local Health District. <br /> County Ordinance No. 18 OENSUS TRACT ms's <br /> JOB ADDRESS/LOCATION �. <br /> Phone "3r <br /> Owner's Name City ` <br /> AddressPhone <br />"` - License # <br /> Contractor's Name <br /> RECONDITION /� DESTRUCTION <br /> TYPE OF WORK (Check): NEW WELL �ION ILII � REPAIR /� PUMP REPLACEMENT <br /> PUMP INSTAL 0 <br /> other /1 <br /> SEWER LINES OTHER <br /> 1� DISTANCE TO NEAREST: SEPTIC TANK _ CES CESSPOOL <br /> PIT <br /> `/ SEWAGE DISPOSAL FIELD .__ <br /> 7� PROPERTY LINE - PRIMATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USETYPE OF WELL Dia. of Well Excavation z" <br /> Industrial Gable Tool <br /> Drilled Dia. of Well Casing <br /> Domestic/private --—r— Driven Gauge of Casing <br /> Domestic/public Gravel Pack Depth of Grout Seal Irrigation Rotary Type of Grout <br /> -�� Cathodic Protection other Other information' <br /> Disposal ---- Surface 5ea1 installed B f <br /> �^Geophysical <br /> PUMP INSTALLATIrOI Contractor H.P. <br /> Type of Pump <br /> PUMP ENT: // State Work Done <br /> REPLACEM <br /> PUMP 'REPAIR: / State-Work!Doue-� ---- <br /> Approximate Depth <br /> ES' RUCTION OF WELL: Well eter <br /> DescibemMaterial and Procedure <br /> 11n <br /> with all laws and regulations oWelleco struction•LoWithincal aFIFTEENtDAYS <br /> I hereby agree to comply to or regulating <br /> and the State of California pertaining <br /> ter completion of ropy work on a new well, i will furnish the San Joaquin Local Health Distr ct <br /> of mF them before putting the -well in.use. The above <br /> WELL DRILLERS REPORT of heebes l nmy know g <br /> information is true to t knowled a and belief. I WILL CALL FOR A�GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED DRAW LOT PLAN ON <br /> SE SIDE <br /> FOR EP T USE ONLY <br /> F PHASE iJ DATE <br /> APPLICATION ACCEPTED BY, <br /> ADDITIONAL COTS:I GROUT INSPEC ION PHASE III FINAL DASTPEECTION <br /> I+�SEN <br /> -PHAW <br /> INSPECTION BY �- <br /> .DATE INSPECTION� BY <br /> - 1-74 2M <br /> E R 1426 Rev. 1-74 <br />