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- N DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 W <br /> APPLICATION FOR WE CONSTRUCTION OR PUMP PERMIT Permit No. 2n <br /> :THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued b.139j7 <br /> (Complete In Triplicate) p,�6 qvo' 31 <br /> Application is hereby made'-to the San Joaquin Local Health District for a permit to construct.'' <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance 'No. 1862 and the Rules and Regulations of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 1 <br /> PhonyV --.2R,< <br /> Address City <br /> Contractor's Name } L %J��/Ll License ��zwz�, <br /> hone /2 <br /> _ .TYPE!O WORK (Check) :___HEW,_WELL -Af-.-DEEPEN / /�RECOND.ITIOH, IBJ DESTRUCTION- / <br /> PUMP INSTALLATION PUMP REPAY/ /`�-PUMP REPLACEMENT /7 <br /> Other J-1 <br /> # DISTANCE TO NEAREST: SEPTIC TANK V <br /> L9A&SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE, DOMESTIC WELL Q_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> r Industrial Cable Tool Dia. of Well Excavation / <br /> ' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> } Cathodic Protection Rotary--: a ; Type of Grout <br /> .Disposal Other ------ Information <br /> Geophysical Surface Seal Installed B : <br /> � <br /> PUP INSTALLATION: Contractor <br /> Type, of Pump — H.P. <br /> PUMP' REPLACEMENT: / / ' State Work Done <br /> PUMP .REPAIR: / / State Work_ Done <br /> E&TRUCTION;-M_WELL: Well Diameter _ �. 3 —Approximate-Depth F- �- <br /> r-- Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> fte'r` completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERSREPORT of the well and notify them before putting the -well in use. The above <br /> - <br /> information is true to the best of. my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR° TO GRO N AND AFI AL PECTION. I <br /> I <br /> t SIGNED /� . TITLE � <br /> pRAW-'PL T- PLAN 'ON REVERSE SIDE) !' <br /> FOR-DEPARTMENT---USE-ONLY'—- <br /> W_. <br /> „ PHASE I,���. -�.�,..�. <br /> APPLICATION ACCEPTED BY a DATE ` <br /> ADDITIONAL COMMENTS: + <br /> PHASE, jj GROUT INSPECTIONP I/FINAL INSPECTION <br /> INSPECTION BY DATE - •1 INSPECTION BY DATE -1 <br /> # 3/7�/2M <br /> ... E H 1426 Rev. 1-74 F=! <br />