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SAN JOAQUIN�LOCAL HEALTH DISTRICT <br /> - Hazelton Ave. , Stockton, Calif. <br /> FOR OFFICE USE: � 1601 E. <br /> { Telephone: (209) 466-6781 permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT -------- <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 74-26 <br /> (Complete In Triplicate) <br /> Application is hereby made to he San JoaquihLocal alication istmade inrict rco pliancea permit twith San uJoaquin . <br /> and/or install the work herein described. T pP <br /> County Ordinance No. 1862 andthe Rules and Regulations of 'the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> • Phone <br /> Owner's Name4 <br /> �n, <br /> City _ = <br /> Address 15 <br /> License <br /> � 7 <br /> License #&�-- 3 Phone 3 i <br /> Contractor's Name i <br /> -_ T•. _.. .u_ _ <br /> ' WORK (Check) : NEW WELL / I DEEPEN / /_ RECONDITION DESTRUCTION <br /> TYPE OF W ( pump REPAIR /� PUMP PUMP INSTALLATION / / .. <br /> Other <br /> i SEWER LINES PIT PRIVY OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT <br /> SEWAGE DISPOSAL FIELD 4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation � <br /> rivate Drilled Dia. of Well Casing <br /> Domestic/p <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Te of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal i other --_--�`' <br /> � q-4;- <br /> urace Seal Installed <br /> Geophysical B <br /> 1 Pi3MP INSTALLATION: Contractor H.P. <br /> Type hof Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> f _p(7MP"REPAIR: /"'State Work �Doiie <br /> F DESTRUCTION OF WELL: Well Diameter <br /> r Approximate Depth <br /> Describe Material and Procedure <br /> hereby a of the San Joaquin Local Health District <br /> I her y tee to comply with all laws and regulations g <br /> and the State of CaliforniZ pertainingto <br /> or <br /> regulating <br /> egul tingshethecSantJoaquin•LocalhHealth District a <br /> after completion of my work on a new <br /> well, above <br /> WELL DRILLERS REPORT of the welland <br /> notify them beforend putting <br /> the well inWILL CALL FOR AeGROUTeINSPECTION <br /> F information is true to the best y <br /> PRIOR TO G OUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED1, <br /> DRAW P.1101' PLAN 'ON RE E'�tSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I w '' # DATE 7 - <br /> APp ATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: 1 PHA AL INSPECTION <br /> + PHASE111" GROUT INSPECTION INSPECTION BY 1 DATE - <br /> INSPECTION BY-' DATE <br /> f 3/7;6 <br /> v D 1426 Rev. 1-74 <br />