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[ — <br /> SAN JOAQUIN LUUAL ft-UALlla ll1J.il�il .f. a <br /> OFFICE USE: 1601 Eelton Ave. , Stockton, Calif. ; <br /> TG.Lephone : (209) 466--6781 1 �/ <br /> 40 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' d� "3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued37� <br /> (Complete In Triplicate) <br /> lication is hereby made to the San Joaquin Local Health Di rict for a permit to construct <br />/or install the work herein described. This application `'s in compliance with San Joaquin <br /> aty Ordinance No. 1862 and the Rules and Regulations of t J:�9tvuin Local Health District. <br /> ADDRESS/LOCATION. �` !'` c.n CNSUS TRACT <br /> ergs Name QUI a x- Phone <br /> cess City - �r <br /> tractor's Name vg License 1 Phone <br /> t <br /> E OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> STANCE TO NEAREST: SEPTIC TANK :LeV' 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 /> Industrial Cable Tool Dia, of Well Excavation <br />_ Domestic/private Drilled Dia, of Well Casing, <br />_ Domestic/public Driven Gauge of Casing <br />, 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: <br /> INSTALLATION: Contractor <br /> Type of Pump H.P. <br />�P REPLACEMENT: / State Work Done L4/I/ i ce 7 z,�6 i�wc — /cV i xz L- fife� - ---- <br /> I,fP -.REPAIR: / / State Work Done <br /> i•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations- of the San Joaquin Local Health District <br /> d the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />�LL DRILLERS REPORT of 6e well and notify them before putting thewell in use... The above <br /> formation is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GROUTING AND A FINAL INSPECTION. <br />,GNED �.+..�. TITLE. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> MASE I <br />'PLICATION ACCEPTED BY DATE <br />)DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 4SPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> I E H 1.426 Rev. - l-74 <br />