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G arcnE�' <br /> r601 <br /> AN JOAQUIN LOCAL HEALTH. DISTRICT <br /> LOEFIE. Hazelton Ave, , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> PLICATION -FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. R <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is hereby made to the. San (Joaquin eIn Local Triplicate) <br /> District for a permit to con <br /> and/or install the work herein described. This application is made in compliance with San uJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a / <br /> CENSUS TRACT <br /> .Owner's Name <br /> t <br /> ' Phone <br />. Address ✓ / ' <br /> City <br /> w <br /> Contractor's Name i <br /> F <br /> License #1!212-), --Phone —2�7� L6 <br /> TYPE OF WORK (Check) : NEW WELT; z <br /> / / DEEPEN /_/ RECONDITION /�' DESTRUCTION /� <br /> PUMP. INSTALLATION. W PUMP-REPAIR / I PUMP REPLACEMENT- 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ <br /> SEWAGE DISPOSAL FIELD PIT: PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDEDUSE <br /> PROPERTY LINE -!.PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool v <br /> Dia, of Well Excaation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotar k <br /> Y Type of Grout <br /> Disposal OtherGeophysical <br /> Other -Information . .;; <br /> Surf ace. Seal Installed B <br /> PUMP INSTALLATION; Contractor <br /> 0/V <br /> Type of Pump <br /> .ri J H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ---------------- <br /> PUMP <br /> II " State Work Done <br /> s�" 4J <br /> DESTRUCTION OF WELL: Well Diameter 4 <br /> Describe Material and Procedure Approximate Depth <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 we11 "c_onstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish:..the 'San Joaquin Local Health District a y <br /> TELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> Lnformation is true to the best of m -kn- ledge nd-belief: I WILL CALL FOR A GROUT INSPECTION j <br />'RIOR TO GROUTING ANDA FINAL INSPE ON. <br /> SIGNED ZZI ITLEi� �I' <br /> D W P T L "ON RE 'SE SIDE <br />'RASE I <br /> R DEPARTMENT USE ONLY 1 <br /> TPLICATION ACCEPTED BY G <br /> JDDITIONAL COMMENTS: ATE <br /> PHASE II G T INSPECTION F F N INSPECTION <br /> INSPECTION BY _ DATE' INSPECTION BY / DATE <br /> _5- <br /> E H 1426 Rev. 1-74 3/76Y 2M <br />