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G /J -:. ._ <br /> (/t,,r,[ � SAN JOAQUIN LOCdAI�,HEALTH.DISTRICT <br /> ' f, . <br /> .pOT'OFFICE USE- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 4) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 5--)3-26 <br /> THIS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <br /> (Complete In Triplicate) t&-3 _. �o&(-(2- <br /> l the San Joaquin Local Health District for a permit to construct <br /> Application is hereby made t <br /> { and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the SanJoaquin Local Health D3sCrict. <br /> 4e, CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> fEPhonez, <br /> M, <br /> owner's Name `Y � <br /> City <br /> Address <br /> License J6F>3)3Phone <br /> Contractor's Name - <br /> ,. . .�� _��:_�.c•--..�...tip- - ��_��=--��- -- <br /> TYPE OF WORK (Check) : NEW •WELL DEEPEN j/ 'RECONDITION_/ I DESTRUCTION "/-T <br /> PUMP INSTALLATION / / PUMP.REPAIR PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE 0 - WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> -� Irrigation �� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection`s Rotary Type of Grout <br /> Other Information <br /> � Disposal - Other ,. <br /> Geophysical Surface Seal Installed $ <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump — — <br /> PUMP REPLACEMENT / /� State Work Done <br /> PUMP :REPAIR: ""/ /I-State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth ��• <br /> Describe Material and Procedure <br /> f <br /> I hereby agree to comply. with all laws 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 /> well, I will furnish the San Joaquin Local Health District <br /> after completion of my work on a new <br /> WELL DRILLERS REPORT of the well and 'notify them before putting the well in use. The above <br /> e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> information is true to the best of my. knowledg <br /> PRIOR TO UOUTING AND A FINAL INSPECTION. TITLE ,g,, <br /> SIGNED ^ . . <br /> •; D W.:Pi� T' PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE}I .� o f Q - DATE l f 7 C <br /> APPLICATION'ACCEPTEDr`BY "` <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE ' <br /> INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1- 74 <br />