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E o` SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> t1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOE OFFICE USE: <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p <br /> Date Issued 7` <br /> THIS PERMIT. EXPIRES l .'YEAR. FROM DATE ISSUED <br /> (Complete In Triplicate) permit to construct <br /> Iric <br /> Application is hereby made to thecrbedaquThisLocal <br /> applicati application inrca pliance with San Joaquin, <br /> F and/or install the work herein• ds <br /> the Rules and Regu <br /> County Ordinance No. 1862 and the of the San Joaquin Local Health District. <br /> lj CENSUS TRACT <br /> JOB ADDRESS/LOCATION 1 2100 G .. <br /> 'Phone �2- Z <br /> Owner's Name <br /> City `. <br /> Address <br /> _ License #G�' Phone <br /> Contractor's Name ' <br /> PE OF WORK (Check): NEW WELL/-T DEEPEN '/ / RECONDITION /�7 DESTRUCTION <br /> TY PUMP REPLACEMENT /7 <br /> PUMP- INSTALLATION / / PUMP REPAIR/�/ <br /> f Other <br /> SEWER LINES `-( QPIT PRIVY r- <br /> DISTANCE TO NEAREST: SEPTIC TANK'�^© - =- OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PLIC ESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICAT ONS <br /> INTENDED -,USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation • <br /> Drilled Dia. of Well Casing 3' <br /> Domestic./private <br /> Driven Gauge of Casing <br /> DomDepth of Grout Seal <br /> estic/public ` <br /> Irrigation Gravel Pack <br /> Te of Grout <br /> l Cathodic Protection : Rotary Other Information <br /> Disposal Other r <br /> f <br /> � Surace Seal Installed <br /> Geophysical B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ' / ""State Work Done _ <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> rict <br /> I=ereb agree to comply with all aws and regulat ons of the Sastruction.Local <br /> WithinaFIFTEENtDAYS <br /> � y <br /> and the State of California pertaining to or regulating we the Sa <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> above <br /> WELL DRILLERS REPORT of the well and notify themabeefoore�ipe£ttiI WILL CALL FOR A GROwell in use. UTINSPECTION <br /> information true the est of my knowledge <br /> PRIOR TO GROU G I INSPECTION. TITLE .. <br /> SIGNED D W 'Pii T PLAN ON RE FRSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> - PHASE I E[/ <br /> F APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p NSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION=E DATE <br /> INSPECTION BY DATE <br /> 3/76 2M <br /> H,a1426 Rev. 1-74 <br />