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Tom` " SAN JOAQUIN LOCAL HEALTH. DISTRICT � <br /> 1601 E. Hazelton Ave. , Stockton, <br /> Calif. <br /> FOE OFFICE USE: <br /> Telephone: (204) 466-6781 Permit No. 1� <br /> APPLICATION FOR WELL-CONSTRtIGTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 7 10/ <br /> (Complete in Triplicate) a permit <br /> struct <br /> Application is hereby made to the San Joaquin Local <br /> licatiolth District forcompliancetwithnSan Joaquin <br /> made <br /> and/or install the work herein described. pp <br /> County Ordinance Na. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ; <br /> o <br /> 4 /LOCATION /V <br /> G—r�Q'rj , ENSUS TRACT j <br /> JOB A <br /> Owner's Name �G <br /> V`✓'K Gam" Phone <br /> ��- <br />` Address <br /> S d, License . Phone �'T �/� <br /> Contractor's Name <br /> f RECONDITION / DESTRUCTION /� <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN / I pip REPLACEMENT I7 <br /> PUMP INSTALLATION I -PUMP REPAIR I.I <br /> Other <br /> SEWER LINES SPIT PRIVY-- --T <br /> DISTANCE TO NEAREST: SEPTIC`TANK © OTHER <br /> SEWAGE DISPOSAL FIELD �� CESSPOOL/SEEPAGE PIT LO �. <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" <br /> PUBLIC DOMESTIC WELL <br /> �-- TYPE•OF WELL `� r --CONSTRUCTION- SPECIFICATIONS <br /> INTENDED USE- Y Dia: ©f Well Excavation / /' e_ <br /> Industrial Cable Tool <br /> Drilled Dia. of Well Casing <br /> X Domestic/private <br /> Domestic/public Driven Gauge of, Casing <br /> `�— <br /> Irrigation Gravel Pack Depth'of`Grout Seal <br /> ga <br /> k e of,.Grout <br /> f Cathodic Protection Rotary d T Other Information _ <br /> Disposal Other __ Surface Seal Installed <br /> Geophysical U. <br /> 4��' llrrs s �.--.. <br /> PUMP INSTALLATION: Contractor H.P. <br /> { Type of Pump ' --- <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: eter <br /> Describeell mMate rial and Procedure <br /> f agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I hereby g <br /> AYS <br /> and the State of California pertaining to °I willlfurnishethe cSan tJoaquin'L calhHealthin TDistEEN rict <br /> after completion of my work on a new well, above <br /> .WELL DRILLERS REPORT of the well and notify them <br /> ndfore belief putting <br /> I WILL CALL use <br /> GROUT eINSPECTION <br /> } information is true to the.best a y <br /> PRIOR TO GROUTING AND A FINAL INSPECTION TITLE <br /> SIGNED ,. -�- -, <br /> L ON REVERSE SIDE) <br /> 0 DEP NT USE ONLY �y <br /> PHASE I DATE <br /> APPLICATION ACCE s� Mi <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE - <br /> ' INSPECTION BY DATE <br /> . 3/76 2M <br /> E H 1426 Rev. 1-74 <br />