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SAN JOAQUIN LOCAL HEALTH.DISTRICT � J9 <br /> FO& OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> } Telephone:. (209) 466-6781 permit No, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE•.IS•STJ <br /> ..Date Issued ,7� <br /> (Complete In Tri.plicate)"� <br /> Application is hereby made to the San Joaquin Local ica.tionDistmade inra permit co plianceto construct <br /> with San Joaquin <br /> and/or install the work herein described, This application <br /> County Ordinance No. 1862 and the ales and Regulations of the San J�ofaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION t� ��7J <br /> 4 <br /> Phone <br /> Owner's Name <br /> City <br /> .� Address C> <br /> License <br /> Contractor's Name <br /> y1� <br /> DSTRUCTION <br /> TYPE OF WORK (Check) . NEW WELL DEEPEN /�PiJMPREPAIR /NII p EREPLACEMENT 17 <br /> PUMP INSTALLATION <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IT PRIVY OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEPLIC DOSTIC <br /> PIT { <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLCONSTRUCTION SPECIFIC WIWS \ <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation t <br /> Domestic/private _, Drilled Dia. of Well .Casixig . <br /> Domestic/public 4 <br /> w Driven Gauge of Casing \ <br /> I Irrigation Gravel Pack Depth of Grout Seal2:115 7j! <br /> ` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ` <br /> Geophysical ,A Surface Seal Installed B <br /> � 1 �v00, , . . <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pup <br /> PUMP REPLACEMENT: . / /� State Work Done - -_ <br /> PUMP-.REPAIR: <br /> State Work Done �- � e '"""` �-'•"� �--`� --.,,� <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 4 ' <br /> ith all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply w <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN RAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT <br /> fthe thabove <br /> e best lof�mynknowle ged otify m ndfbelief. I WILL CALL FOR AGROUT ore putting the -well in eeINSPECTION <br /> information is true to <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNEDDg�,W.r _T PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I DATE �-- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> INSPECTION BY <br /> PHASE II TE EC, INSPECTION BY DATE N.. �7 .� � '-�- " <br /> Oman <br /> �. <br /> 3/76 <br /> E H 1426 Revl�" ��"" - <br />