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SAN JOAQUIN„LOCAL HEALTH DISTRICT <br /> 1601 E. HazeltnriAve. , Stockton, Calif . t <br /> FOF OFFICE USE: <br /> �.. Telephone: ` (2O9) 466-6781 d <br /> APPLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Date Issued <br /> 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> Application is hereby made td the San Joaqud. in Local Healio District- fmade inrcompliancea permit twith nSan uJoaquin <br /> and/or install the work herein describe <br /> County Ordinance No. 1862 and the. Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION p <br /> l7`9,y� Phone G <br /> Owner's Name C Q-6111? <br /> � •l�rt�kcdb City <br /> Address <br /> License # � � Phone <br /> Contractor's Name <br /> PE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /� <br /> TY PUMP REPLACEMENT <br /> PUMP <INSTALL.ATION �^PU'RP REPAIR / <br /> Other. <br /> SEWER}LINES.. PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/-SEEPAGE PPIT;�, OTHER <br /> SEWAGE tDISPOSAL FIELD PUBLICfDOMES'TIC WELL <br /> . PROPERTX --.LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE 'OF WELL <br /> Industrial 1 Cable,Too1� Dia. of Well Excavation <br /> t Drilled Dta- --of Well Casing <br /> Domestic/private Driven _ of Casing <br /> Gauge <br /> Domestic/public 1 <br /> Irrigation ;� Gravel Pack Depth of Grout Seal <br /> T e of 7�Grout <br /> Cathodic Protection �I Rotary Other Information <br /> Disposal Other <br /> f Seal Install <br /> Geophysical <br /> Surface ed B <br /> IF <br /> c <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / 4 State Work Done <br /> _ t <br /> PUMP .REPAIR: / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure' <br /> I hereby agree to comply with all las odoreregulating well'construction.ulations of the San oaquinLoWithinaFZ TEENtDAYS <br /> and the State of California pertaining <br /> after completion of my work on. a new well, Louse.cal <br /> WELL DRILLERS REPORT of the well and notify t <br /> information is true to the'rbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING AND INAL INSPECTION. TITLE ` <br /> SIGNED (DRAW PLAT PLAN ON REVERSE SIDE) <br /> ..FOR_DtPARTMENT.USE_ONLY V �. <br /> f PHASE I ,� ' DATE v2- <br /> 79 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: f pHA S III/FINAL INSPECTION <br /> PHASE II GROUT INSP CTION INSPECTION BY DATE <br /> f INSPECTION BY DATE <br /> 0/77 <br />