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k �Co N /(",4/ <br /> SAN .TOAQUIN LOCA <br /> L <br /> �'- ( ` ICUSE:E METH DISTRICT <br /> -�- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP P <br /> ERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROMDATE ISSUED <br /> f Date Issued gS <br /> (Complete In Triplicate) <br /> Application is hereby made Ca the Satz Joaquin Local Health District for a <br /> and/or install the work herein described. permit to construct <br /> . County Ordinance No. 1862 said the Rules and Reisulat�one tofnthe S d Joaque in onpLocaleHealthwith sDi Joaquin. <br /> .TOB ADDRESS/LOCATION <br /> District. <br /> i� c.�C S ce.� �a.� � G <br /> {D ENSUS TRACT l <br /> i Owner's Name <br /> _ Phone <br /> Address d2 oZ�� i KJ atC51 // <br /> City <br /> Contractor's Name - <br /> �'6 License # L22i_jZ-Phone 2,67-6 <br /> TYPE OF WORK (Check) : NEW WELL '/? DEEPEN '/? RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP .INSTALLATION / ./ PUMP REPAIR '/? PUMP REPLACEMENT <br /> Other �/ / / <br /> DISTANCE TO NEAREST: SEPTIC :TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL SEEPAGE PIT <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC STIC WTELL1� ~} ' <br /> INTENDED USE TYPE D�' WELL .,� <br /> �- _ Industrial CONSTRUCTION SPECIFICATIONS N j <br /> Cable Tool Dia. of Well Excavation <br /> — Domestic/private <br /> Domestic/publicDrilled Dia. of Well Casing <br /> ' Driven <br /> IrrGauge of Casing <br /> igation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' . <br /> Geophysical . _ : _ ----�-- <br /> - 7, Surface Seal Installed. B � <br /> 'PUMP INSTALLATION; Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: / / State Work Done ± <br /> DESTRUCTION OF WELLi- Well Diameter ' <br /> Describe Material and Procedure Approximate" Depth -- <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District- <br /> and the State of California pertaining to or regulating well 'cons-truction. Within FIFTEEN DAYS <br /> after completion oft"my work- on a new well, I will furnish the .San Joaquin Local Health Distrit a <br /> WELL DRILLERS REPORT,of the well and notify them before putting.-the..well. in.use.... .The above c <br /> information is true to the-best-of..my..knowled e a d elief. I WILL CALL FORA GROUT INSPECTION <br />'RIOR TO GRmTywn AND A FINAL INSPECT <br /> SIGNED � <br /> E <br /> (D W LOT P ON RE SIDE) -. — <br />,HASE I FOR DEPARTMENT USE ONLY <br /> 0'P ATION ACCEPTED BY <br /> 1DDITIONAL COMMENTS-: DATE 1-7 5 <br /> "PHASE II GROUT-IN PECTION 3 <br /> NSPECtlN) $�' - PHASE III FINAL INSP <br /> DATE . INSPECTION EY . <br /> t ' D <br /> E H 1426Revy . " <br /> . 1-74- -. <br />