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-.� J SAN JOAQUIN LOCAL HEALTH DI/RZCT , <br /> E7FFICE USE: 16j1?=_-E,.Hazelton Ave. , Stockton, C��Iifc . <br /> E Telephone: (209) 466-6781 <br /> APP ICATION FOR WELL CONSTRUCTION DR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l -I -2 <br /> (Complete in Triplicate) _ tiuct <br /> k Application is hereby made to the San <br /> quThisuin Local <br /> application istrict made inrcop l ancetwithnSan Joaquin <br /> and/or install the work herein described. <br /> nd Re ulations ,gf -t e .S n 3�juin L cal Health District. <br /> County Ordinance No. 1862 and the Ru es <br /> C NSUS TRACT <br /> JOB ADDRESS/LOCATION LL� .' / <br /> hone <br /> owner's <br /> Owner's Name lti <br /> 1 City <br /> k Address <br /> 1 License # Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ' / RECONDITION /_1 DESTRUCTION <br /> T_I- <br /> PUMP .INSTALLATION / / PUMP REPAIR /_/ <br /> Other. / / > <br /> DISTANCE TO NEAREST; SEPTIC TANK � SEWER LINES PIT PRIVY 20 <br /> d <br /> SEWAGE DISPOSAL FIELD �f CESSPOOL/SEEPAGE PIT DOMESTIC WELL )e�l <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'— PUBLIC CONSTRUCTION SPECIFICATIONS <br /> 1NTENDED USE TYPE OF WELL -- <br /> Industrial Cable Tool Dia. of Well Excavation 77.17- <br /> 9.- <br /> i <br /> Drilled Dia. of Well Casing '! <br /> Domestic/private Driven Gauge of Casing <br /> ,Domestic/public 4 .. ---. <br /> Irrigation., Gravel Pack. Depth of-Grout'S'adi1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal" Other Other Information <br /> Geophysical <br /> �• Surface Seal Installed B ` <br /> r a <br /> PUMP INSTALLATION: Cont�ractarJ`i H.P. <br /> Type of Pump r�r... <br /> PUMP REPLACEMENT i I�I ; State Work Done A <br /> PUMP .REPAIR: �¢ f / }'' State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and ce ure <br /> I hereby agree to comply with all . aws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish .the San Joaquin Local Health District <br /> -,JELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND INAL IN ECT IO TITLE <br /> `..a : <br /> SIGNED <br /> DRAW RSE SIDE <br /> I' DT L ON. VE . <br /> Y <br /> R DEPARTMENT USE ONLY Q <br /> PHASE I DATE Q <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMEN�S: e PHA IF SPECTIO <br /> PHA I G . UT INSPECTI INSPECTION BY ATE <br /> INSPFCTIO BY DATE <br /> 4 /a GclZlf a �; 3 3/76 2M <br /> w <br /> 1-74 <br /> + E .�i 1426 Rev• <br />