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SAN JOAQUIN LOCAL HEALTH.DISTRICT ' <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOE OFFICE USE: <br /> Telephone: (209 466-6781 <br /> ) Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued X27 <br /> (Complete In Triplicate) permitrict <br /> A lication is hereby made to the San Joaquin LoccalHealthlicationDistmade inrco plancetwithnSanuJoaquin <br /> PP <br /> and/or install the work herein described. This PP k <br /> Count Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. } <br /> County ` Z �S e �d CENSUS TRACT <br /> JOB ADDRESS/LOCATION / �_� W <br /> Phone g 3 R` 7 -Y 7 <br /> Owner's Name . <br /> .N city <br /> Address 30 / s- R '� � �'� � <br /> License Phone <br /> Contractor's Name IL <br /> i' DESTRUCTION /7 <br /> TYPE OF WORK (Check) : NEW WELL DEPT — PAIR f RECONDITION I/ PUMP REPLACEMENT 1_7 <br /> PUMP INSTALLATION <br /> Other 4 / <br /> SEPTIC� / SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEWAGE DISPO/SAL FIELD � CESSPOOL/SEEPAGE PIT OTHER <br /> WELL <br /> PUBLIC DOMESTIC <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Cable Tool Dia. of Well Excavation <br /> Industrial Dia. of Well Casing 1 a� <br /> Domestic/private Drilled D <br /> Driven Gauge of Casing <br /> Domestic./public� Y Gravel Pack Depth of. Grout Seal N <br /> Irrigation {�� Rotary Cathodic protection # y Type of Grout <br /> Other Other Information <br /> ' . Disposal Surface Seal Installed B : <br /> Geophysical <br /> PUmP'`--INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> f PLWSP REPLACEMENT: <br /> State Work-Done <br /> State Work Done <br /> PUMP .REPAIR: <br /> F, Approximate Depth. <br /> DESTRUCTION OF'':WELL: Well Diameter <br /> T Describe Material And Procedure <br /> I h reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ruction. Within FIFTEEN <br /> I <br /> and the State of California pertaining to or ri111furnishethecSantJoaquin Local Health District 2 <br /> AYS <br /> f after completion 'of my work on a new well, w above <br /> WELL DRILLERS REPORT of the well and notify them <br /> beforend putting <br /> WILL CALL FOR A GROUT-well in use. eINSPECTION <br /> information is true to the best ofE��knowledge <br /> PRIOR TO G OUTING AND A FINAL TITLE j <br /> SIGNED �'� <br /> T)RAW PTU ' PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY <br /> DATE <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: F E FIN NSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY ATE - 2 �� <br /> INSPECTION BY i DATE <br /> £, 3/714 <br /> V v 1A99 Raw_ 1-74 <br />