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+� 6 SAN JOAQUIN-I.00Af HEALTH DISTRICT <br /> FflF�;flFFICE USE: �Ij �1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' ► '' Telephone: (209) 466-6781 <br /> G APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1304✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. -//-7 <br /> (Complete. In Triplicate) Z?CQ(t,0-2--,— <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> mrd/oir instar. the work herein described. permit to construct <br /> This la iication -is made. in compliance with San Joaquin <br /> Cvuaty Ordinance No. 1$62 and the Rules and uia ons of ,the San Joaquin .Local. Health District. <br /> ;2-3 <br /> 7- <br /> 1 � r te. <br /> ,TOB ADDRESS/LOCATION� �!7L �. � S <+- CENSUS TRACT <br /> i <br /> k <br /> Owner's Name Phone , <br /> Address .2/. € t�Q�-- p <br /> city <br /> Contractor's Name 45, ' <br /> License PhoneL <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN '/'? RECONDITION %r DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ ` PUMP REPLACEm /7 <br /> Other f07 — <br /> DISTANCE TO NEAREST: SEPTIC TANK /a SEWER LINES PIT PRIVY w <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATiON5 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private r Drilled Dia. of Well. Casing typff <br />�_- _- - <br /> Domestic/public.���,� �.Driven �.,� Gauge of Casing -� <br /> Irrigation mGravel Pack, Depth of Grout Seal <br /> Cathodic Protection �� Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .° H.P. <br /> PUMP REPLACEMENT: • <br /> State Work Done <br /> PUMP '.REPAIR: /7 :State Work Done <br /> DESTRUCTION OF WELL,; Well. Diameter Approximate Depth <br /> Describe Material and Procedure " <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 "construction.. Within FIFTEEN DAYS <br /> after.' completion of my -work on a new well, I will furnish the San Joaquin Local Health District a <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 CALL 'FOR 'A 'GROUT INSPECTION <br /> PRIOR TO G OUTING 'AND• A NAL I ECTI N. <br /> SIGNED TITLE <br /> D PLOTL ONREV SE SIDE J <br /> FOR-DEPARTMENT U15E ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY <br /> DATE /C <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT <br /> +INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 3- -�f INSPECTION BY DATE <br />' E 11426 Rev. 1-74 �ryc �u <br />