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t / SAN .30AQUIN LOCAL HEALTH DISTRICT <br /> FOFi+OFFIGE USE: I/ 1601 E. Hazelton Ave. , Stockton, Calif, 3 <br /> Telephone: (209) 466-6781 Permit No. . ? <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEST <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED * <br /> (Complete In Triplicate) a permit � <br /> hereby made to•the San Joaquin Local Health D strict <br /> tmade inrcv pliancel Health Districttrdith San Joaquin <br /> Application is he y <br /> Regulations of the San Joaquin .Loca .. <br /> District- <br /> and/or install the work herein deecribed�. This applicat on <br /> County Ordinance No. 1862 and the Rules and Reg p� CENSUS TRACT <br /> 30B ADDRESSILOCATION IS73"? <br /> 3 ' <br /> Phone <br /> Owner's Name <br /> . Citq <br /> Address ,0 ,t''► <br /> j:,Z;V7 <br /> License # � Q1(� Phone <br /> E Contractor'B 'Name <br /> RECONDITION IT DESTRUCTION I=T <br /> ' TYPE OF WORK (Check)t NEW WELL I? DE <br /> PE PUMP <br /> REPAIR y, PUMP kEPLACEMENT jg <br /> PUMP T ALLAT3 <br /> Other %/ ..��.,:��� �:•'..�� --� . .� . <br /> ' - <br /> SEWER LINES IT PRIVY <br /> DISTANCE-T07NEAREST SEPTIC TANK CESS OOP L/SEEPAGE PI _ OTHER <br /> } SEWAGE DISPOSAL FIELD �^ PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' \ <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of Well Excavation V <br /> Industrial Cable Tool <br /> /private ��, Drilled � Dia. of Well Casing <br /> Domes tic/p Gauge of Casing, ' � t <br /> Domestic/public _,,_ Driven Depth of Grout SealGrave ¢ <br /> Irrigation .^ , Rotaryl Pack Type of Grout _ <br /> Cathodic Protection <br /> � -- �- Other �_____�, Other Information � 1 <br /> Disposal ��---- Surface Seal Installed .B <br /> = Geophysical <br /> k PUMP INSTALLATION: Contractor H,r, <br /> Type .of Pump <br /> Work Done Wo <br /> PUMP REPLACEMENT: ' // State - _ - <br /> ' 41 <br /> PUMP.REPAIR: , t.Ptate Work Done. r <br /> � h <br /> M - Approximate Dept ----� <br /> r DESTRUCTION OF WELL: = Well.-Diameter <br /> k. <br /> Describe;14aterial and Procedure <br /> lth <br /> rict <br /> I hereby agree `to comply with .all laws and regulations pwelleconstruction.LoWithincal aFIFTEENtDAYS- <br /> f and the State of California pertaining to or regulating <br /> above <br /> after comp ERS <br /> mp'work on a new well, I will furnish the San Joaquin Local Health District <br /> i WELL DRILLERS REPORT of the well and nknowled eify them <br /> andbefore <br /> belief. I WILL CALL FO A GROUTeINSPECTION <br /> information is true to the-best-of y g <br /> PRIOR TO GROUTI G ANDA XIN& INSPECTION. TITLE <br /> SIGNEDDRAW PLOT PLAN ON REVERSE SIDE <br /> FOR .DEPARTMENT USE ONLY <br /> PHASE IDATE O <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMS: PHAS I INSPEGTIO <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY <br /> DATE <br /> t ff 2M <br /> 7-7A <br />