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J �SAN JOAQUIN'LOCAL HEALTH. DISTRICT ,, <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />` ! Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6-s 9 k,� <br /> _ THIS.-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 <br /> '' (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. is ,application 'is made in compliance with San Joaquin" <br /> County::Ordinance No. 1862 lland the Rules 4W Regulations of IQ San Joaquin Local Health District'. <br /> JOB ADDRESS/LOC i <br /> CENSUS TRACT <br /> Owner's Name . Phone <br /> Addresszo 3 Q!`-�� � city Ll w <br /> Contractor's Name ^� License <br /> • 1 <br /> TYPE OF WORK (Check) : NEW WELL -'DEEPEN -/-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ''PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT THER ( � <br /> PAOPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE Og,WELL CONSTRUCTION SPECI I IONS N <br /> Industrial :� _ Cable Tool Dia. of Well Excavatiop <br /> — — Domestic/- ° Drilled f 4Dia.,of Well Casing <br /> Domes ic.% ublic 1 �! Driven ` Gauge'of Casing <br /> z I <br /> ,p <br /> Irrigation i .. . .Gravel-PAck� G €Depth of Grout Se'L <br /> C <br /> athodic Protection i 1/Rofary ; Type of Grout <br /> _ isposal t Other _ Other Information` . <br /> eophysicalSuxf ace Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type Of-PUMP A.P. <br /> PUMP REPLACEMENT / / State Work Done f <br /> PUMP�REPAI : r % i tState-Work;-Done - = <br /> rox '` <br /> �. DES•TRUCTION OF WELL: Well Diameter App imate Depth <br /> De P <br /> Describe Material and Procedure <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'construction. Within FIFTEEN DAYS <br /> after completion of my work{on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thelwell and notify them before putting the-well in use. The above <br /> F information is true to the best of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED, TITLE <br /> D W.P PLAN ON RSE SIDE <br /> �. FWpAPARTUSE ONLY <br /> PHASE I <br /> y <br /> APPLICATION ACCEPT�H.BY 09DATE �Z3 <br /> ADDITIONAL -COHN9NTS: 1 <br /> PHASE 11 GROUTIINSPECTION PHASE III/FINAL INSPECTION; <br /> INSPECTION BY3DATE _ -5= G INSPECTION BY DATE 6 <br /> E H 1426 Rev. 1-74 3/Tb <br />