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`L SAN JOAQUIN LOCAL 'HEALTH DISTRICT n ►: <br /> !p jore <br /> * FOB•rOFFICE USE: 1601 E. ,Hazelton Ave. , Stockton, Calif. <br /> F Telephone: (209) 466--6781 <br /> APPLICATION FOR FELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT .EXPIRE$ 1 ,YEAR FROM DATE ISSUED Date Issued <br /> ;,(Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> . the work herein described.° This application is made -in compliance with San Joaquin. <br /> andfor installand the- Rules and. Regulation's of the San Joaquin Local Health District. <br /> County Ordinance e k h <br /> 34B ADDRESS/LOCATION . : 6 6 <br /> dJr CENSUS TRACT <br /> Phone <br /> Owner's Nance <br /> City <br />� . Address <br /> t j License # 72,1 Phone - 6 <br /> Contractor's. Name <br /> TYPE 0WO (Check): NEW WELL ./? DEEPEN /_7 RECONDITION /? DESTRUCTION 9f7 <br /> . � PUHP;.INSTALLATION, /­ I PUMP REPAIR I I PUMP REPLAC <br /> { ; Other !I <br /> [ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT. OTHER <br /> Sn <br /> IC LL <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL�NSTRI PUBLIC SPECIFICATIONS oC <br /> ' ST <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia, of Well Excavation <br /> 4�e_ Domestic/private Drilled Dia. of Well Casing <br /> "Dvmes'tic/public .Driven Gauge of Casing <br /> I Irrigation Gravel Pack-• Depth of Grout Seal <br /> Cathodic Protection 7 Rotary Type of Grout <br /> Other Information <br /> Disposal Other <br /> i Geophysical Surface Seal Installed By:.- <br /> PUMP INSTALLATION: Contractor ~ -- H.P. 3 <br /> Type, of Pump .r..d/ <br /> I <br /> PUMP REPLACEMENT: /X/ State Work Done A 'd` <br /> PUMP 'REPAIR: 5tate Fork�D'one <br /> E&TRUCTION 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 /> i 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}bes of my .knouledge and belief. . I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALSP a ITLE <br /> SIGNED <br /> RAii+� • LOT PLAN ON ERSE SIDE <br /> E FOR DERWrMENT USE NLY <br /> PHASE I - S DATE <br /> APPLICATION ACCEPTED BYE, <br /> ADDITIONAL COMMENTS: y j PHASE III FINAL INSPECTIO <br /> PHASE II GROUT INSPECTION INSPECTION BY ATE <br /> INSPECTION BY i DATE <br /> E ,51-7 4 2H <br /> E R 1426 Rev: 1-74 <br />