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I- - -: -'"-v'—rrWVV" L <br /> SAN JOAQUIN LOCAL HEALTH DIS TRICT.. _° <br /> �� 1601 E. Hazelton Ave. , Stockton, Calif., �t1 f1 +- <br /> FO3.__. CE USE <br /> '. Telephone: (209) 466-6781. � <br /> , t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> e*N 16 1976 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issu _ <br /> (C,omplete In Triplicate) <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 aneJoa u°n Local eHealth with SDistrian ct. <br /> County Ordinance No. 1862 and the Rules and Regulations of the q <br /> CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION <br /> L. <br /> Owner's NamePhone <br /> l�l� dL R-0 ' <br />' city <br /> Address <br /> License # Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEWWELL / DEEPS / / RECONDITION / / DESTRUCTION /-7-- /-7 <br /> -7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT / <br /> f Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> : <br /> PROPERTY LINE'-."PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE f TYPE OF WELL` CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Industrial <br /> Domestic/private . <br /> Dulled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> k Cathodic Protection Rotary Type of Grout <br /> g. / Other Other Information <br /> �eophsaical ' Z Surface Seal Installed By : <br /> ' PUMP INSTALLATION:"° ,j., Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> L.P.,AV I�)� 0 L 19 W IF L L 2 � 7✓� � • Approximate Depth <br /> � DES•TRUCTION OF WELL: W ll Diameter <br /> 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"constructi.on. Within FIFTEEN DAYS <br /> I will furnish the San Joaquin Local Health District <br /> after completion of my work on a new well, <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'TIN AND FINAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> 'APPLICATION^ACCEPTED BY . .. <br /> ADDITIONAL COMMENTS: PHASE I /FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE z� 7B <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rev. , 1-74 -- J" <br />