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' l,wE. _._may �awrusi.m+,-.-,r m-•-••a`-:-Yti. <br /> a ,SA <br /> I JOAQUIN LOCAL HEALTH. DISTRICT- <br /> FOR OFFICE USE: -7601 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 FROM DATE ISSUED Date Issued <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. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the ,Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a CENSUS TRACT <br /> Owner's Name h, Phone f ..3 7 <br /> Address . <br /> City <br /> Contractor's Name -� License IV6 23-2 Phone ( 4 <br />-TYPE-OF�WORO' cfierk) "NEW° WEL;T�=J `DEEP'NT-/_/ --RECONDITION—/ 4 DESTRUCTION'%7``--­� <br /> AL <br /> PUMP INSTALLATION / / PUMP REPAIR -/Wr_' PUMP REPLACEMENT /-J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> C <br /> Industrial-. .:} Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - -.I--rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal `�- _ Other Other Information <br /> Geophysical �- Surface Seal Installed BY: ^r <br /> � C <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Donez <br /> PTTFfP REPAIR: _ - - - -if_g�...,,- - <br /> 'S"tate Work--D=6 - — - - y.-- � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District g <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS 4 <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 the well and notify them before putting the..well in use. The above .4 <br /> information is true to the est of my..kno edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROM NG D INSPECT <br /> SIGNED TITLE <br /> Df W PMT PLAN ON REVERSE SIDE) 'i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE L-l2--7 <br /> ADDITIONAL COMMENTS: -� <br /> PHASE II GROUT INSPECTION PWA F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY' .- 1L . ! I . . . (1YDATE i <br /> E H 1.426 Rev. -l-74 • <br /> 3/76 . 2M <br />