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'��''7 SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton,, Calif., <br /> r, <br /> Telephone: (209) 466-6781"• <br /> LCTIu�V O�R WELL CONSTRUCTION OR PUI4 PERMIT Permit No. <br /> H XPIRES 1 YEAR FROM LATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sa Joaquin Local Health District for a permit to construct.. , <br /> and/or install the wojk �W did r bed. This application is made in compliance with San Joaquin <br /> County Ordinance No-. `TBi �gn4jtfffgt4 les an a ulations f the San Jo uin Local Health District. <br /> �r - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name y <br /> Phone4 4� <br /> Address <br /> City <br /> Contractor's Name �' lVel "PS License <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/—/ RECONDITION / / DESTRUCTION /? <br /> AL � (� } <br /> PUMP INSTLATION PUMP REPAIR /� PUMP REPLACEMENT /� pg ' <br /> Other Z_/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WE .L , <br /> INTENDED USE TYPE OF -WELL , CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia. of We11. Excavation j <br /> >, <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven- Gauge of Casing <br /> Irrigation Gravel Pack' i Depth 'of Grout Seal <br /> Cathodic Protection : Rotary Type of Grout <br /> Disposal Other Other Information <br /> —Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump., i <br /> A.P. <br /> Ii <br /> a. <br /> PUMP REPLACEMENT: . /.; / State Work Done,' � <br /> PUMP .REPAIR: State Work Doo - <br /> DESTRUCTION DF 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 D!A.YS. <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-beat of my-knowledge and belief. I WILL CALL FOR A GROUT &SPECTIOW <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED If 4L.= iT 7777,010 TITLE <br /> D W !Tl—PLAN ONE)SIDE �'.!_,." �...,,� .,,,..�, �,I <br /> PART T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT ML�U LI DATE l ` <br /> ADDITIONAL GOMM9NTS: - <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION :• <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ' V76 2#,-C13 <br />