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KV SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . I / Telephone: {209} 466-6781 �Sa2� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> kl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued A__Zk___76 I <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Health Distrmade inra permit co compliance San <br /> construct <br /> Joaquin <br /> and/or install the work herein described. This application i <br /> County Ordinance No. 1862 and' the Rules and Regulations of the San Joaquin Local Health District. +1 <br /> CENSUS TRACT • <br /> JOB ADDRESS/LOCATION I` r p► <br /> Phone 0 l e— " <br /> Owner's Name <br />� - <br /> Address z � City <br /> �# <br /> License #/A Z 3 73 phone V�" <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL /_£ DEEPEN / / RECONDITION / �E CION <br /> MENTI� <br /> PUMP INSTALLATION/ / PUMP REPAIR I4I UM <br /> Other / / <br /> 4 <br /> DISTANCE TO NEAREST: SEWAGE DEPOSAL FIELD <br /> LINECESSPOOL/SEEPAGE PIT OTHER <br /> PIT PRIVY <br /> SEWAGE <br /> PROPERTY LINE �- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> C <br /> INTENDED USE TYPE OF WELL ONSTRUCTION SPECIFICATIONS <br /> Industrial {t Cable Tool Dia.. of Well Excavation Q <br /> Drilled Dia. of Well Casing <br /> Domestic/private <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection . Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> �, <br /> PUMP INSTALLATION: Contractor H.P. <br /> ! ,Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> eeded <br /> t„- -ti -_Y_�Sta�te=Work-;-D � 4��'`` .;/f U <br /> Pi]MP"REPAIR:��" <br /> Approximate Depth <br /> Describe Mat <br /> � DESTRUCTION OF WELL: We11� Diameteerial and procedure <br /> I hereby a o comply wi h all laws and regulations of the San Joaquin Local Health District <br /> and the ate of alifornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after (IUILER <br /> pletion f my work on ew we , I will furnish the San Joaquin Local Health District a <br /> WELL REP RT of th' we and of fy them before putt the..well in use. The above <br /> info ation s to eb t a ovule ge an e e I WILL C A GROUT INSPECTION <br /> PRIG TO N AND ON. <br /> ` SIGNTITLE <br /> i llRAW PI; T PLAN ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IZ1 - DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHA I/F NSP�ECI <br /> PHASE IY GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> 3/76 2M <br /> • f <br /> V. T4 1426 Rev. 1-74 - <br />