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FO&.OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FRO <br /> M DATE ISSUED Date Issued 82. <br /> Application is Hereby made to the San{Joaquin Lo al Hlete In ealth District for a <br /> and/or install the work herein described. This a <br /> County Ordinance No. 1862 an the R permit to construct <br /> application 18 -made in compliance with San Joaquin <br /> s and of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q �}�-�)E p <br /> Owner's Name � �,�•••.� _ _ , <br /> cENsus TRACT <br /> Phone 7—,7,f <br /> Address - <br /> !! l� City - cop<f� <br /> Contractor's Name <br /> License 1461 73Phone <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN 1_7 RECONDITION _ <br /> PUMP IN5TALLATION / / PUMP REPAIR .? DESTRUCTION /-7 <br /> , <br /> Other /% / PUMP REPLACEMENT / <br /> DISTANCE TO NEAREST: SEPTiC <br /> SEWAGE DISPOSAL FIELD <br /> EWER LINES PET PRIVY _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '— <br /> ELL 'COSSPOOLSEEPAPUBLIC STICTHER <br /> INTENDED USE TYPE OF WELL WELL—� <br /> Industrial CONSTRUCTION SPECI <br /> /private FICATIONS <br /> Domestic �-.�,, Cable Tool Dia. of Wel Excavation <br /> Domestic/public Driven�� Drilled Dia. of Well Casing <br /> �� q <br /> Irrigation Gauge of Casing <br /> Cathodic Protection Gravel Pack Depth of Grout Seal <br /> Disposal Rotary Type of Grout <br /> Geophysical Other Other Information <br /> Surface Seal Installed B <br /> PUMP INSTALLATIONa Contractors <br /> Type of Pump <br /> • H.P. ' <br /> PUMP REPLACEMENT. - %/ State Work Dane <br /> IUMP 'REPAIR.* <br /> State Work Done <br />)ES•TRUCTION OF WELL Well Diameter <br /> Describe Materialand Procedure Approximate Depth <br /> hereby agree to comply with all laws grad regulations of the San Joaquin Local Heal <br /> ind the State of California pertaining to or regulating well "construction. th District { <br /> after _completion of my work on a new well, I will furnish the San Joaquin LocalhHealthTDistrict a <br /> ILLMDREPORT of the well and notify these before putting.the..well. in.use.... The above <br /> nformation is true to the-best-of my knowledge and belief. I WILL CALL FOR A GROUT <br /> RIOR�"�TO GROUTING AND A FINAL INSPECTION. INSPECTION <br /> TITLE <br /> 11" <br /> (DRAW PLOT PLAN ON REVERSE' SIDE <br /> RASE t N FOR DEPARTMEfi1T USE ONLY <br /> PPLICATION ACCEPTED BY <br />-DDITIONAL COMMENTS.: DATE , <br /> PHASE II <br /> Q1101,11 INSPECTION <br /> 4SPECTION BY DATE PHASE II INAL INSPECTION <br /> INSPECTION B DATE <br /> r <br /> E H 1426 Rev. 1-74 <br />