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FOE.OFFICE USE "`" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No.?— °2964 <br /> THIS PERMIT- EXpiRES I YEAR FROM .DATE -1.SsU <br /> ED <br /> Application is hereby made to the San (Joaquin Local lete riplicate) Date Issued <br /> and/or install the work herein described. I{eAlth District for a <br /> Count o co <br /> Ordinance No. 1852 and. This appcation is made in compliancePermit twith nSan uJoaquin <br /> Y the Rules and Re of the San Joaquin Local <br /> JOB ADDRESS/LOCATION ' Health Distract. <br /> Owner's Name I. CENSUS TRACT <br /> ._ . <br /> Address p Phone <br /> Contractor's Name City <br /> License #phonep 9 <br /> TYPE OF WORK <br /> (Check)s NEW WELL -/7 DEEPEN -/-7_ <br /> PUMP INSTALLATION RECONDITION / DESTRUCTION /_7 <br /> Other /� PUMP REPAIR L_7UMp REPLACEMENT %f <br /> ,DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOS EWER LINES PIT PRIVY <br /> PROPERTY LINE - PRIVATE DOMESTICSSEEPAGE PIT....... OTHER <br /> TENDED U5E TYPE OF WELL PUBLIC DOMESTIC WELL— r , <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/Private ----- Cable Tool Dia. of Well Excavation <br /> Domestic/public Drilled Dia. of Well Casing O <br />.� Iriiigation Driven Gauge of Casing <br />.�.� Cathodic Protection " "�- Gravel pack Depth of Grout Seal <br /> Disposal f --,�_ Rotarq Type of Grout <br /> Geophysical Other Other Information <br /> Surface Seal Installed 'B <br /> Pi 11P INSTALLATION,; <br /> . Contractor <br /> Type-of Pump <br />'UMP REPLAC H.P. <br /> EMEN1TJe / State Work Done <br />'UMP !REPAIR: <br /> )L-7 State Work Done <br /> E&TRUCTION OF;WELL: Well Diameter <br /> Describe :Matexial and Procedure Approximate Depth <br /> hereby agree to comply with all Taws and regulations of the San J • � <br /> nd the State of California pertaining to or regulating well ":constru9uin Local Health District <br /> Eter completion of Within <br /> my work e a new well, I will furnish the San Joaquin•Local Health a <br /> AYS <br /> ELLjDRILLERS REPORT of the well and notify them before r' <br />'formation s true to the'best of. Putting. the..well in.use... The above <br />'.GN TO TING AND a►F knowledge and belief. I WILL L FOR A GROUT INSPECTION <br />�GNED NAL SPECTION. <br /> DRAW PLOT PLANON REVERTITLSE SIDE <br /> LASE I - FOR DEPARTMENT USE ONLY <br />'PL A ION ACCEPTED BY <br /> DITIONAL COBS; DATE ��[ •�� <br /> PHASE II GROUT INSPECTION <br /> 5PECTION BY DATE PHASE III FINAL INSPECTION <br /> INSPECTION BY <br /> F DATE 17 <br /> E H 1426 Rev. 1-74 <br />