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SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> -FO-F--'OFFICE USE. �� 1601 E. Hazelton Ave. , ,Stockton, Calif. 'F <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP"1PERMIT Permit No. 7- 160Df <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) a <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 nd the Rules an eg lationsnof the San Joaquin Local Health .District, <br /> JOB ADDRESS/LOCA <br /> CENSUS TRACT i <br /> Owner's Name Pho `, X <br /> i <br /> Address . , y <br /> Phon <br /> Contractor's Name .LicerX' <br /> ��_ <br /> TYPE OF WORK (Check) : NEW'WECL / J DEEPENRECONDITION-/7yIESTRUCTION`�/ 1 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT I T M y <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ;. <br /> SEWAGE DISPOSAL FIELD. ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE '-=''PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE CTYPE OF WELL , - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation . <br /> Domestic/privatei ; Drilled Dia. of Well Casing <br /> Domestic/public , ` Driven _ .. Gauge of Casing <br /> Irrigation ' Gravel. Pack A jDepth of Grout Seal <br /> Cathodic Protection Rotary` :Type of Grout <br /> Disposal # Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUN? INSTALLATION; Contractor r <br /> Type of Pump H.P. <br />: PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR; State Work Done x <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth � - <br /> Describe Material and Procedure <br /> r � <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health bistrict <br /> and the State of California pertaining to or regulating well ''construction. Within. FIFTEEN DAYS <br /> after completion of my work on a new well, Twill furnish the San Joaquin Local Health District a <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> e, 6I.e r� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> gGROUT <br /> FOR DEPARTMENT USE ONLY <br /> PHADATEAPPLICATION ACCEPTED ADDITIONAL COMMENTS:PHASE II IN PECTION PHArSE,,14r/FINALAWSPECTIOt4 <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> 1177 2M <br /> E H 1426 Rev. 1-74 <br />