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- - i <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> �/ Stockton, Calif. <br /> FOR OFFICE U E: 1601 E. Hazelton .Ave. , <br /> \ _ L .... <br /> Telephone: (209) 466-6781 Permit No. <br /> UR <br /> • - APPLICATION FOR WELD" CONSTRUCTION OR PUMP PERM - f 7 � } <br /> Date Issued Y 1f <br /> THIS"PERMTT EXPIRES 1 YEAR FROM DATE ISSUED O��r 2C�r r <br /> (Complete In Triplicate) <br /> reb made to the San -Joaquin°Local Health "istmade in compliance ct fotwith San Joaquin <br /> Application is he y <br /> -/This application <br /> and/or install the work herein described, uin Local Health District. <br /> County Ordinance No. 1862 and Rules and Regulations of the San Joaq <br /> ` CENSUS TRACT <br /> JOB ADDRESS/LOCATIONz g' <br /> i IJ Phone <br /> Owner's Name <br /> Ci <br /> ty ez N <br /> C Address _( phone <br /> —License,#107f <br /> Contractor's Name <br /> RECONDITION� DESTRUCTION <br /> DEEPEN '/ / <br /> TYPE OF WORK (Check) : NEW WELL <br /> PUMP INSTALLATIOI PUMP REPAIR/ I PUMP REPLACEMENT I ;n <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 3f PIT-PRIVY ______ OTHERS <br /> t CESSPOOL/SEE AGE PIT <br /> SEWAGE DISPOSAL FIELD �� 5.1- PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC <br /> WELL PUBLIC <br /> SPECIFICATIONS F <br /> TYPE OF WELL i F <br /> INTENDED USE Cable Tool = Dia: ofL Well Excavation, <br /> Industrialr• <br /> :3—z--Drilled pia.�:of Well Casing; >< � .�. <br /> Domestic/private Gau e`,-of-Casing <br /> ublic Driven <br /> Domestic/p De Ch' of Grout Se <br /> Irrigation T -� =aC <br /> Gravel- -- F <br /> Cathodic Pro_ teen on .'- Rotary Type�°f a^ --�-- <br /> - — Other Other' Information <br /> Di.spos�a1 � Surface_ Seal Installed $ c <br /> Geophysical <br /> - f <br /> PUMP INSTALLATION: Contractor C S H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done _ <br /> Se Wo <br /> Stat rk-`Done ,.• - <br /> PUMP .REPAIR:~ � : <br /> --- _ Approximate Depth -------- <br /> s DESTRUCTION OF WELL: Well Diameter.— <br /> ocedure <br /> Describe Material and Pr <br /> 11 <br /> Ill <br /> lth <br /> 4 comply with all laws and regulations of the oWithin cal nFIFTEEN tDAYS <br /> rict <br /> I hereby agree to p Y regulating well,-construction. <br /> and the State of California pertaining to or reg gJoaquin Local Health District <br /> after completion of my <br /> work on a new well, I will furnish , he San Joaq The above <br /> WELL DRILLERS REPORT of the well and nknowledgeify mandbefore <br /> belief lI WILL CALL FOR Aut-� ng the well in eGROUT INSPECTION <br /> information is true to the best y rte <br /> PRIOR TO GROUT AND A FI INSPECTION.""-��' <br /> TITLE U <br /> ` <br /> SIGNED D W.:p�; T' PLAN ON RE ELSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE' <br /> I APPLICATION ACCEPTED BY # <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION' <br /> PHASE II GROUT INSPECTION INSPECTION By DATE <br /> DATk; <br /> INSPECTION BY 3I76 2M <br /> U 149 Rev. 1-74 - <br />