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� SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FORYOFFIWE USE: 44& 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 � <br /> THIS PERMIT EXPIRES I YEAR FROM DATE- ISSUED Date Issued - i 7 <br /> (Complete In Triplicate) . <br /> n6trct <br /> Application is hereby made to the San. Joaquin LocalHealth <br /> District made for <br /> capermit p liancewithto cO SanuJoaquin <br /> and/or install the work herein described. This app <br /> . nd the Rules and Regulations of the San Joaquin Local Health Aistrict. <br /> County Ordinance No. 1862 a <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Phone <br /> Owner's Name <br /> �7 /(r� C/2�-� � City <br /> Address ` <br /> � License hone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : . NEW WELL DEEPEN / RECONDITION / / DE5TRUCTION -LACEMENT�1 <br /> PUMP INSTALLATION Z -PUMP REPAIR / / PUMP REP _ <br /> Other <br /> DISTANCE'TO` NEAREST: SEPTIC TANK 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD'_ CESSPOOL/SEEPAGE PIT OTHER <br /> WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> OI— PLICVSTRUCTION SpEMECIFZCATIONS <br /> STIC <br /> 'INTENDED -USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled <br /> Dia. of Well Casing (� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �iC/� /1'J <br /> Other Other Information ' <br /> Disposal <br /> Geophysical Surface Seal Installed "B <br /> �� - .� <br /> PUMP INSTALLATION: Contractox .. __ P. <br /> J <br /> Type o f--Pump. 3 <br /> PUMP REPLACEMENT: / S tate..Wofk Done <br /> PUMP .REPAIR: _ _ /�/ State Work Donees <br /> DESTRUCTION-DF_.WELL:. _ .Well,Dimmeter <br /> Approximate Depth _ <br /> Describe Material, and Procedure \ <br /> ith all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply wFIFTEEN:-DAYS and the State of California pertaining to or regulating we 11'construction. Within FIFTEEN:BAYS <br /> k on a new well, I will furnish the -San Joaquin Local Health District <br /> I aftercompletion of my wor <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU GD A FINAL ZN CTION. TITLE <br /> i SIGNED v >._.. ,,. <br /> T'' PLAN ON RE'�LRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE. -1 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY INSPECTION BY �°-D3 DATE �! <br /> Y 3/76 2M <br /> E H 1426 Rev. 1-74 <br />