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SAN JOAQUIN LOCAL HEALTH DISTRICT Calif . <br /> 1601 E. Hazelton Ave. , Stockton, <br /> FOL OFFICE USE: Telephone: (204) 46b-6781 PERMIT Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete In Triplicate} permit to construct <br /> hereby made toIthe San Joaquin Local Health District for a <br /> her application is made in compliance 'Witth DistrictSan . <br /> Application is Y This pP Joaquin Local <br /> and/or install the work herein described. <br /> Count . Ordinance No. 1862 and the Rules and Regulatio s of the CENSUS TRACT <br /> Y <br /> JOB ADDRESS/LOCATION Li <br /> I � ® Phone <br /> Owner's Name City <br /> 6 <br /> Address License i�P <br /> Phone ' <br /> Contractorts Name l <br /> RECONDITION /-7 DESTRUCTION <br /> NEW WELL //7 DEEPEN / pump-REPLAGEMENT- <br /> TYPE OF WORK (Check) : PU10-REPAIR-'— <br /> PUMP�INSTALLAT.ION-�I <br /> Othex':.1 1 1 - <br /> SEWER LINES !� PIT PRIVY OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK �� �� ,CESSPOOL/SEEPAGE PIT <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC"IWELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL Dia, of We 11�Excavation G <br /> Industrial Cable Tool C <br /> ''� Drilled <br /> Dia <br /> . of Wel'1 Casing <br /> ~~ Domestic/private _�_ Gauge of Casing <br /> Driven <br /> Domestic/public �" Gravel Pack Depth of Grout Seal ` <br /> Irrigation o" Rotary Type of Grout` i] <br /> Cathodic protection �-- other *Information <br /> L Disposal ! Surface Sea] Installed B : <br /> Geophysical , <br /> r � - f Contractor H.P. <br /> l� PUMP INSTALLATION: Type of Pump <br /> ` <br /> r PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR* / / State Work Done <br /> Approximate Depth <br /> DES OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> r <br /> r <br /> with all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply to or regulating we11'construction. Within FIFTEEN DAYS <br /> and the State of California pertaining I will furnish the San Joaquin Local Health Districl <br /> above <br /> after completion of my work on a new well, tting the <br /> r DRILLERS REPORT of the well and notify them ndfbelief- I WILL Ce1L FOR Al in eGROUTeINSPECTIOT <br /> WELL D <br /> information is true-.to the Aest pECTI0Nowledge <br /> PRIOR TO UTING TITLE 0 `1111 <br /> t SIGNED � PLAN ON RE RSE SIDE} <br /> Fp EPART NT U E ONLY <br /> PHASE I , DATE <br /> + APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t pHA III INAL INSPECTION <br /> PHASE II GR T INSPECTION INSPECTION BY DATE <br /> r DATE <br /> . INSPECTION BY 3/ 6 214 <br /> F u 1626 -Rev. 1-74 , <br />