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FOdi P, OFFICE USE; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave, <br /> ,Stockton, Calif. <br /> APPL <br /> Telephone : (209) 466-6781 <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No, � <br /> THIS PERMIT EXPIRES 1 Y <br /> ' EAR FROM DATE ISSUED <br /> Application is G reb (Complete In Triplicate) Date Issued <br /> and/or y made to the San Joaquin Local Health District for a l <br /> r / install the work herein described. This a <br /> County Ordinance No. 1862 and permit to construct <br /> the Rules and application is made in compliance with San ,Toa <br /> JOB ADDRESS egu tions of th San Joaquin Local, Health District. <br /> /LOCATION �Q f <br /> Owner's Name CENSUS TRACT <br /> Address 44p/ .� Phone,?se— V6.Cl <br /> a <br />.`Contractor's Name City , <br /> ` # <br /> License <br /> 7 �6,&Phone <br /> TYPE OF WORK (Check _ <br /> ) : NEW WELL / / DEEPEN =' <br /> PUMP INSTALLATION / / RECONDITT4Nr T` �. <br /> / PUMP J / DESTRUCTION /? <br /> Other /; / .--� REPAIR /':/ PUMP REPLACEMENT /?J' <br /> DISTANCE TO NEAREST; �f-� , <br /> SEPTIC TANK <br /> _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD � <br /> PROPERTY-LINE p CESSPOOL/SEEPAGE PIT <br /> INTENDED USE TYpE OF WELLIVATE MESTIC WELL OTHER <br /> Industrial } PUSLIC D7OMESTIC WELL— <br /> Cable Tool CONSTRUCTION 'SPECIFICATIONS <br /> Domestic/private Dia, of Well Excavation <br /> Domestic/publica Drilled - Dia, of Well Casing <br /> Q� <br /> Irrigation _ Driven Gauge lof.Casing <br /> Gravel Pack -� # Depth hof?Grout Seal v'_ 1 <br /> Cathodic Protection. <br />�_Disposal f Rotary <br /> f � Type of Grout <br /> Geophysicalr,' Other Other Information <br /> Surface Seal Ins <br /> AL :w t <br /> UMP, B <br /> INST CATION• <br /> n... ._- Contactor: - <br /> �Type' of".Pump s <br /> H.P. Nt <br /> JMP REPLACEMENT: State Work Done <br /> .<r <br /> JMP REPAIR: : <br /> State Work Done <br /> S-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health D <br /> d the State of California istrict <br /> ter completion of my work on a-newnwell,oI will regulfurnishethe CSan tJoaquin�Local hHealth Districtin FIFTEEN DAYS <br /> LL DRILLERS REPORT of the well land notify them before putting the. well in use. The above a <br /> formation is true too the best ;of my knowledge and <br />'OR TOGUTING ANM7 A IAL PECT�IO belief, I WILL CALL FOR A GROUT INSPECTION. a� <br /> INS , <br />�NED r <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) r <br /> kSE IIS� FOR DEPARTMENT USE ONLY <br /> ------------------------------ <br />'LICATION ACCEPTED BY <br />)ITIONAL COMMENTS: DATE % ?7 <br /> PHASE II GROUT INSPECTION ` <br />'rPECTION BY f 'f'' PHAS I/FI INSPECTION <br /> DATE INSPECTION BY DATE <br /> k <br /> E H .1426 Rev. 1-74 - t t-7-7 <br />