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. SANOAQ�TIN AL� i3ISTRICT <br /> 1601 E. Hazelton Ave. Stockton,Stockton, Calif. <br /> Telephone : (2.09) 4d6-6781 C <br /> :'LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> x <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> .vreby made to the San Joaquin Local Health District for a permit to construct <br /> and/or"-its ta'lf the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I / R� <br /> JOB ADDRESS/LOCATION <br /> ` CENSUS TRACTJFS—404 -0 ,y <br /> Owner's Name Phone <br /> r <br /> Address <br /> 7 �— L� l - -._ City' ��}'✓`D <br /> r _` <br /> Contractor's Name x`13 �n �m �._ j�1�r <br /> License �� 7�,,C>���Phone� �-C� a <br /> TYPE OF WORK (Check) : NEW WELL '/Wf__r'EEPEN / / RECONDITION / / DESTRUCTION /? O <br /> PUMP INSTALLATION /��j'rPUMP REPAIR .I / PUMP REPLACEMENT I� 41- <br /> Other l I G <br /> .f <br /> DISTANCE TO NEAREST: SEPTIC TANK .SQ SEWER L NES .PIT PRIVY &4� , <br /> /S-EWAGE DISPOSAL FIELD ,�-CESSPOOL/SEEPAGE--PIT OTHER ' (r <br /> (_PROPERTY LINE -= PRIVATE DOMESTIC WELL """ PUBLIC DOMESTIC WELL " °. <br /> INTENDED USES- TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> Indus triar,�' . � Cable_,Tool Dia. of Well Excavation <br /> �mesticYprisvate Drilled Dia. of Well Casing s �'r' <br /> Domestic/Ip�blic Driven Gauge of Casing <br /> Irrigation Gravel Pack - Depth of Grout Seal <br /> Cathodic Protection rotary Type of Grout <br /> Disposal Other Other Inf-oYmati.on P• <br /> Geophysical Surf ace Seal Installed B <br /> J PUMPKIN TALLATION: Contractor ELx-t\r\ <br /> f .�.. _. H.P. <br /> Type of Pump r <br /> PUMP REPLACEMENT: / / State Work Done ' f <br /> PUMP .REPAIR: /' / State Work Done <br /> L si� <br /> DESTRUCTION OF WELL: Well D� APProx3mate Depth <br /> metef � , -, <br /> Describe Material and Procedure 4, <br /> f <br /> nI <br /> hereby agree to comply with all laws and regulations of thekSan Joaquin Local Health District ' <br /> k ad the State of California pertaining to or regulating-well_yconstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnishrt'he San Joaquin Local Health District , <br /> WELL DRILLERS REPORT of the well and notify them befdxe putting the -well in use. The above <br /> in tion is true to therbest of owledge and belief. I WILL CALL FOR A GROUT IN <br /> PRIOR ROUTING AND A FIN S <br /> SIGNED R TITLE <br /> OT PLAN 'ON REVERSE SIjE;E <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE . <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE /F INSPECTION <br /> INSPECTION B F DATE : INSPECTIQN BY DATES 2Z 7� <br /> , ; .r, 3/76 <br /> 3��v <br /> E H 1426 Rev. 1-74 _ <br />