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r r0A,OFFICE USE; SAN JOAQUIN LOCAL HEALTHDISTRICT <br /> 1601 E. <br /> Hazelton CT <br /> j Ave.,, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> THIS PERMIT EXPIRES y ; <br /> �' FRflM PATE ISSUED <br /> Application is harsh (Complete In Triplicate) Date Issued <br /> y made ,to the San Joaquin Local Realth Diattict for a <br /> � <br /> and/or install the .work herein described. <br /> County Ordinance NO.-1862 and the Rules andRegulationsof permit to construct <br /> � application is made in compliance with San Joaqu�,n <br /> the San Joaquin Local health District. <br /> � <br /> JOB ADDRESS/LOCATION � T l <br /> Owner's Name SUS TRACT <br /> Address-- 7 4 Phone „A 0 7 <br /> . ' � <br /> Contractor's Name90, <br /> City ' <br /> f <br /> f Licensed�--3 7 2 Phone 3 c <br /> TYPE OF WORK (Check): NEW WELT, ~ <br /> /_7 DEEPEN/-7 RECONDITION /_� DESTRUCTION <br /> J <br /> PUMP INSTALLATION / / PUMP REPAIR N <br /> Other /% /� PUMP REPLACEMENT <br /> DISTANCE TOST:ST. SEPTIC TANK <br /> SEWAGE DISPOSAL FIELDER FINES PIT PRIVY <br /> CESS OP OL/SEEPAGE PIT_ <br /> a 711111 ''I'llINE _ PRIVATE DOMESTIC WELL OTHER <br /> PROPERTY L <br /> INTENDER USE ;TYPE' OF WELL <br /> Industrial PUBLIC b MESO TIC WELL <br /> CONSTRUCTION _§PECIFICATIONS <br /> Doutestic --�.._ Cable Too3 Dia. of WeII Excavation <br /> /Private � Drilled � <br /> Domestic/public Dia: of Well Casing q, <br /> IrrigationDriven a__Gauge of _Casing <br /> __ =Cathodic Protection - Graveyl Pack Depth of Grout Seal - - <br /> _,_Disposal Rotar <br /> Other € Type of Grout <br /> _-,____Geophys ica.l Other A lnfoj"t#on <br /> . Surface Seal Installed B ; <br /> PUMP INSTALLATION: <br /> Contractor x <br /> Type of'.Pump <br /> PUMP REPLACEMENT.- H•P• _.I <br /> tate Work Done.P00 <br /> PUMP 'REPAIR: - "°' '� � �..-- <br /> `7 State Work Done <br />)ES-TRUCTION OF WELL: Well Diameter — - <br /> Describe Material and Procedure Approximate Depth <br /> C hereby agree to comply with all laws <br />:nd the State of California pertaining to o� regulating well construction. Wit <br /> an ragulatians of the San Joaquin Local Health District <br /> tfter completion of my work on a new well, I-will furnish the San Joaquin Local I <br /> FELL DRILLERS REPORT of the well and notify ', hem before bin Health <br /> District <br /> DAYS <br />.nformation is rue to the best a£ m Putting- the- well in use..HeThehaboverict a <br /> RiOR TO GROU G A N my-knowledge and belief. I WILL <br /> IGNED INSPECTI N, CALL FOR A GROUT INSPECTION <br /> ' TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> iASE I F FOR DEPARTMENT USE ONLY <br />•'P'L TION ACCEPTED BY { <br /> 3DITIONAL COMMENTS: DATE C/11 <br /> PHASE IIGROUT IN PECTION <br /> fSPECTION BY DATE PHASE III F INSPEC IO <br /> INSPECTION BY DATE ,3 <br /> E H 1426 Rev. 1_74 <br />