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V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> e1601 E. Hazelton Ave. , Stockton, <br /> FOE OFFICE USE: Telephone: (209) 466-6781 Permit Na. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED — <br /> Date Issued f�18"�6 <br /> (Complete -In Triplicate} ermit to construct <br /> plication is made in <br /> compliance with San Joaquin <br /> Application is hereby made to .the SaquThisoapp cal Health Dis.tride in a p l Health District. <br /> and/or install the work herein described. <br /> County Ordinance No: 1862 and the Rules and Regulations� of the .San Joaquin Local <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION ��� �� y 13 <br /> Phone <br /> Owner's Name <br /> City <br /> Address <br /> License #�� _ phone <br /> Contractor's Name <br /> DESTRUCTION /� <br /> �-' RECONDITION�/!� <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN �PUMP REPAIR INTI P� MEPLACEMENT I� <br /> PUMP INSTALLATION �/ , * <br /> Other 1 / <br /> SEWER LINES PIT PRIVY _ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK _�_ CESSPOOL/SEEPAGE PITS <br /> SEWAGE DISPOSAL FIELD -PUBLIC DOMESTIC WELL <br /> PROPERTY LINE -- -PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> . Dia. of Well Excavation <br /> Cable Tool <br /> Industrial Drilled Dia. of Well Casing <br /> Domestic/private Gauge of Casing <br /> Domestic/public Driven <br /> �- Gravel Pack Depth of Grout Seal. <br /> Irrigation Rotary Type of Grout <br /> Cathodic Protection y Other Information <br /> Disposal Other <br /> Surface Seal Installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> f Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> d. REPAIR:. 4 <br /> /�-State Work Donee <br /> PUMP <br /> Approximate Depth <br /> DES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> lth <br /> rict <br /> to comply with all laws and regulations of the ori tructfon.Loca With�inaFIFTEENtDAYS <br /> and the <br /> agree P Y <br /> and the State of California pertaining to or regulating well c <br /> after completion of my work on a new well, I will furnish thenSa San <br /> the .well i ovaluseHealth <br /> above District <br /> The <br /> RILLERS REPORT of the well and notify them before <br /> putting <br /> to the best of my knowledge and belief. I WILL CALL FOR A GROUT IN <br /> information is true SPECTION <br /> WELL D <br /> PRIOR TO G OUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED DRAW PIS T PLAN ON REVE72SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE` I DATE /C "f <br /> APPLICATION;ACCEPTED By <br /> .ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II .GROUT INSPECTION INSPECTION BY E <br /> INSPECTION BY A DATE <br /> 3/76 1214 <br /> `. F. T3 1426 Rev. 1-74 <br />