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o . <br /> FOE:'OFFICE tfSE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. <br /> Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r <br /> THIS PERMIT EXPIRES .I YEAR FROM DATE 'ISSUEDe <br /> (Complete In Triplicate) Date Issued X26 <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permit and/or install the work herein described. This application is made in compli_ancetwitonSan Jo <br /> County Ordinance No. 1962 and the Rules and Regulations of the San JoaquinLocal Heath Sea District. <br /> JOB ADDRESS/LOCATION Health District. <br /> Owner's NameLW <br /> CENSUS TRACT <br /> „� t f <br /> Phone , <br /> Address �� All 1 <br /> Contractor's Name . City " <br /> License Phone <br /> TYPE OF WORK (Check): NEW WELL ' DEEPEN -/_7_ <br /> PUMP INST LATION RECONDITION /7 DESTRUCTION /_7 <br /> Other / / PUMP REPAIR/? PUMP REPLACEMENT %'7 <br /> DISTANCE TO NEAREST: <br /> SEPTIC TAN SEWER LINES v <br /> SEWAGE DISPOS PIT PRIVY <br /> PROPERTY LINE -- CESSPOOL(SEEPAGE PIT OTHER <br /> INTENDED USE DOMESTIC WELL` PUBLIC DOMESTIC WELL~ <br /> Industrial TYPE OF WEL _# ` CONSTRUCTION SPECIFICATIONS <br /> �� Cable Tools <br /> Domestic/private Dia. of We11 Excavation <br /> Domestic _ Drilled Dia. of Well Casing lJ <br /> /Public � j� <br /> 46Irrigation Driven Gauge of Casing <br /> Gravel Pack ' <br /> Depth of Grout Seal <br />.,�,,,_ Cathodic Protection Rotary � <br />_.�Disposal _ Type of Grout <br /> ,,,_,.,Geophysical Other Other Information <br /> Surface Seal Installed 'B i <br /> PUMP INSTALLATION: ` <br /> Contractor <br /> -Tyke of Pump _ <br /> l' ' H.F. <br /> PUIT';REPLACEMENT: / / State Work Done <br /> P__UMP- <br /> .State--Work° Done= a' <br />>ES4RUCT110N, Of' WELL: Well Diameter c � <br /> Describe Material and Pracedur _ APProximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin End the State of California Pertaining to or regulating r the Sa tJoagian. <br /> oaquin Local Health District <br /> iter completion .of my +work on a new well, I will furnish the San Joaquin LocalWithHea$th Din ENtDAYS <br />`ELL DRILLERS REPORT of the well and notify them before putting. the.:well. in-use.. District a <br /> nformation is true tot beat o my-know ge and belief. I WILL CALL 'FOR A 'GROUT I 4i <br /> TOR TO The above <br /> TING AND N IN CTION. NSPECTION <br /> IGNED . <br /> TITLE <br /> ' (DRAW PLOT PL ON REVERSE SIDE <br /> FOR DEP <br /> ASE I <br />'P TCL ATION' ACCEPTED BY »' <br />)DITIONAL COMMENTS: DATE S Zgr <br /> PHASE II ROUT SPECIION 7h t c 4s0 t <br />�SPECTION BY DATE BY PHASE III FINAL INSPE IO Ps' <br /> INSPECTION -DATE <br /> El <br /> 1426_ Rev. 1-74 <br />