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� SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOE OFFICE USE: 1601 E. Hazelton4Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f- <br /> 11 ' ' ' (Complete In Triplicate) p 53- 0 0 �� � <br /> is hereby made to the San Joaquin Local Health District for a per9t to onstru toa Joaquin <br /> Application y <br /> and/or install the work herein described. This application is made in. compliance with an q <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Districgf <br />{ - y� + �, CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone7­�:21_0_ <br /> Owner°.s Name - <br /> Address S-7/ ( City c <br /> Contractor's Name Licensef Ca 3 Phone �J <br /> e <br /> TYPE OF WORK (Check): NEW WELL /� DEEPgZ / RECONDITION / / DESTRUCTION - <br /> i PUMP INSTALLATION / / PUMP REPAIR �-PUW REPLACEMEPiT <br /> Otheir / <br /> i DISTANCE TO`NEAREST: SEPTIC TANK SEWER LINES 'PIT PRIVY <br /> SEWAGE DISP'OISAL F ELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE? -'PRIVATE DOMESTIC WELL' -PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial _ Mb le Tool Dia. .of Well Excavation <br /> Domes <br /> ' ' <br /> ic�!piivate lDrilled Dia, of Well Casing <br /> Driven Gauge of CasiA19 <br /> Domes�icl'pubiiq <br /> Irrigeti Gravel Pack Depth of Grout Seal;. <br /> f Catho i`c'Protection Y _` 4 Rotary Type of Grout <br /> Other Information <br /> Disposal Other <br /> Geoph�sical ; `y Surface Seal installed B _ <br /> PUMP INSTAL,i 'TION: Contractgrl i <br /> -. Type of Pu H. <br /> PUMP REPLACEMENT: /� tate W <br /> PUMP .REPAIR: / /State Work Done P, <br /> Approximate Depth <br /> DESTRUCTION OFA. WELL:•° .Wel1 Diameter <br /> Uesdribe Material and Procedure 1 <br /> I hereby agree to comply 'with all laws and regulations of the San' oaquin Local Health District <br /> and the State of California pertaining to or regulating well'construction. Within FIF'PEtN DAYS. <br /> after completion of my work on a new well, I will furnish the SaiiFJoaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting ihe .wel.l in use. The above <br /> information is a to the'be t of my k ledge and belief. I WILL" CALL FOR A GROUT INSPECTION <br /> PRIOR !TO GROUT ANDA FI INSPECTI �' <br /> SIGNED TITLE` <br /> k yd: PLAN ON REVERSE SIDE - . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 4z.17 B) <br /> APPLICATION- ACCEPTED BY <br /> + ADDITIONAL COMMENTS: III FINAL INSPECTIO <br /> PHASE <br /> PHASE II GROUT INSPECTION f;. r <br /> INSPECTION BY DATE _ INSPECTION BY DATE <br /> 3/76 2P4: <br /> E H 1426 Rev. 1-74 r <br />