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42 G r . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , G <br /> E• Hazelton Ave. , Stockton, Calif. �" 1./ <br /> 1b01466-6781. <br /> EOE. OFFICE USE: Telephone • (204) Permit No <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PENT ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued �1 <br /> (Complete In Triplicate) permit to construct <br /> San Joaquin Local Health District in with San Joaquin <br /> Application is hereby made to the application is mad in compliance h. District. <br /> uin ocal a <br /> and/or install the work herein described. This app ` <br /> Ordinance e. 1862.: and `the Rules and Regulations of the. S an J <br /> County � ENSUS TRACT � <br /> JOB ADDRESS/LOCATION U / <br /> p � Phone i <br /> Owner' s,Name/ <br />` Address 1,��.�/jl <br /> I o�License Phone ✓� S� <br /> # �`/ <br /> Contractor's Name <br /> i <br /> 4STRUCTION /_T <br /> EPEN/ / RECONDITIOND_I <br /> SPUMP IN5TALLATION � <br /> TYPE OF WORK (Check) : NEW WELL I/ DEPUMP REPAIR/ / PUMP REPLACEMENT /' / <br /> 7 Other IJ1 <br /> ' PIT PRIVY <br /> ' IC Lr, SEWER LINES OTHER <br /> DISTANCE TO NEAREST: SEWAGE DISP SAL IELD CESSPOOL/SEE AGE PIT �,� <br /> PROPERTY LINE (RIVA E DOMESTI-C WELL PUBLIC DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS \ <br /> INTENDED USE \ , 'TYPE OF WELL "Dia;-of 'Wel'1�Exeavation o� <br /> a. Industrial ' Cable Tool Dia. of Well Casing <br /> omestic%private �nd Gauge of Casing <br /> I-, Domestic/public Depth of Grout Seal. <br /> IGravel Pack <br /> rrigation P c <br /> ary Type of Grout <br /> Cathodic Protection Lomat Other Information <br /> Disposal Other <br /> Surface <br /> Geophysical Seal Installed B <br /> PUMP INSTALLATION: Contractor D�:J� H.P. <br /> Type of rump S <br /> PUMP REPLACEMENT: / State Work'Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESiTRUCTION OF WELL: Well: Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> rict <br /> I hereby agree to comply with all laws •`and regulations of_the San Joaquin Loyc,1�thHnaFIFTEENtDAXS <br /> sand the State of California pertainingjto or regu3ating well'construc uin•Local Health District <br /> . after com e on of my work on a new well., I will furnish the San J q <br /> WELL DRI LETS REPORT of the well and nofify them before putting th we1 in use. The above <br /> inform400ns true t the best of. my knowledge and belief. I -WIL C FOR A G 0 INSPECTION <br /> PRIOR INC INAL INSPECTION. <br /> ' TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR D .ARTMENT USE ONLY <br /> ,PHASE I DATE <br /> ,APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ,.._ .. P I/ INSPECTIO <br /> PHAS II%{GR UT INSPECTI N INSPECTION BY DATE <br /> INSPECTION BY j` > .. DATE /� <br /> 1 r 1177. 2M <br /> ;_7L <br />