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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Permit No. S/!) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made to the San Joaquin Local Health <br /> Distract incompliancewith San Joaquin <br /> PP <br /> and/or install the work herein described. This application i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION KJ / <br /> � �Wl'al Phone <br /> Owner's Name <br /> CityfJ - <br />� Address <br /> F License �� °d1J`S� Phone <br />` Contractor's Namer <br /> 4 <br /> (Check) : NEW WELL � DEEPEN/ / RECONDITION / / DESTRUCTION <br /> �I� <br /> TYPE OF WORK (Ch ) . PUMP REPLACEMENT <br /> PUMP INSTALLATION PUMP REPAIR / I <br /> Other <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO <br /> T: SEPTIC TANK �p CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELDS . <br /> PROPERTY LINF„ PRIVATE DOMESTIC WELLCV CONSTRUCTION <br /> SPMEIZCATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> �-- <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/Public Driven Gauge of Casing _� 7 <br /> Depth of Grout Seal <br /> Irrigation Gravel Pack P <br /> Cathodic Protection _ Rotary Type of Grout .� <br /> Other Other Information <br /> Disposal <br /> Geophysical Surface Seal Installed B <br /> , <br /> ION: Contractor ' `� - <br /> PUMP INSTALLATION: H.P.=° . <br /> I <br /> Type of Pump @ <br /> PUMP REPLACEMENT: / / State Work Done Y <br /> PUMP REPAIR: State Work Done <br /> Approximate Depth, <br /> # pE5•TRt3CTI0N .OF WELL: Well, <br /> DescribeMaterialand Procedure <br /> ` 11 laws and regulations of the San Joaquin Local Health Distri <br /> E YS <br /> I hereby agree to comply with a Within <br /> AYS <br /> and the State of California pertaining to of wigllfurngshethe cSan tJoaquin.Local Health TDistEN rict <br /> after completion of my work on a new well, well in above <br /> WELL DRILLERS REPORT- o 6eell and notfy them <br /> before <br /> belputting <br /> WILL CALL FOR AeGROUTeINSPECTION <br /> information is t e o the best of myknowledge <br /> 1 PRIOR TO GROUT SP ION. <br /> �� TITLE <br /> SIGNED. DREiW '1, 1T�PLAN,.ON_RE ERSE SIDE} � <br /> FOR DEPARTMENT US- <br /> PHASE <br /> �r� <br /> PHASE I DATE 7 l 7 <br /> APPLICATION ACCEPTED Y <br /> ` ADDITIONAL COMMENTS: W PHASE: III/FINAL INSPECTION <br /> PHASE II GR INSPECTION w <br /> INSPECTION BY .,�.+� BATE I <br /> INSPECTION BY �p� <br /> 3/76 2M <br /> v <br /> 11.7A Rav_ 1-74 <br />