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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204*) 466-6781 7LJ <br /> IV CONSTRUCTION OR <br /> APPLICATION FOR WEPUMP PERMIT Permit No. p <br /> 76-J <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date issued <br /> (Complete In Triplicate) <br /> ct <br /> Application is hereby made to the San Joaquin Local ��cis made in compllancetwithnSenuJoaquin <br /> and/or install the work herein described. This application <br /> County Ordinance No. 1862 and the Rules and Regulations. of the San,-Joaquin Local Health District. <br /> CaO�Z �10 . " �� .�•' CENSUS,TRACT <br /> JOB ADDRESS- T <br /> Phone . . . . <br /> Owner's Name <br /> City <br /> Address <br /> Contractor's Name o S <br /> �/a�• / ��;1 <br /> Li cense <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /PUMP REPAIR•/-RECONDITON / DESTRUCTION <br /> PUMP REPLACEMENT <br /> PUMP INSTALLATION <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z470 f-SEWER LINES PIT PRIVY _ <br /> _vim_CESSPOOL/SEEPAGE PIT fJ!J I-OTHER <br /> SEWAGE, DISPO�AL IELD / _ . <br /> f <br /> PROPERTY LINE"�'PRIVATE DOMESTIC WELL'���/PUBLIC DOMESTIC WELL '"7 <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATION . <br /> f Industrial Dia. of Well Excavation <br /> Cable Tool <br /> Domestic/private Drilled Y Dia. of Well Casing <br /> Driven Gauge of Casing =-' <br /> � Domestic/public ��' ��- � <br /> Gravel Pack Depth of .Grout..-Seal ,.,�,�,•, <br /> Irrigation <br /> ' <br /> Rotary Type of <br /> Cathodic Protection gout <br /> Disposal Other Other' InfOrMatian' <br /> - � "`" "'" _ Surface"Seal installed BY: <br /> Geophysical ti <br /> d = e <br /> PUMP INSTALLATION: Contractor v S„1' /. .� <br /> Type �-�- <br /> .of Pump H.P. <br /> PUMP REPLACEMENT: . / -/ State Work Done .: R <br /> PUMP • <br /> 'REPAIR• StaCe..York Done. - } <br /> DESrTRUCTIONOF WELL: Well.,Diameter v Appr Ximate Depth <br /> and.-Procedure <br /> Describe Material and <br /> 4 <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 'constructian. Within FIFTEEN DAYS <br /> ocal Health District s <br /> after completion of my work on a new well, I will furnish-,the San Joaquin L <br /> 'WELL DRILLERS REPORT of the well and notify them before putting.the..well. in'.use.... .The above <br /> information is true to the-best•of my knowledge and belief.., I WILL CALLFOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION ITLE <br /> SIGNED. <br /> i (DjtV PLOT P ON REVERSE SIDE <br /> FOR D P TMENT USE ONLY <br /> ► PHASE i - .DATE ' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE ,,,FINAL <br /> INSPECTION <br /> PHASE II G OUT Ii�SPECTION INSPECTION BY DATE , 2 <br /> 'INSPECTION BY DATE <br /> � . . QP <br /> GM <br />