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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /Ip91� <br />` Date Issued. / =/ -76 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> E (Complete In Triplicate) <br /> o construct <br /> Application is hereby made tki the San Joaquin Local Health <br /> onDistrict <br /> inrco pliancea permit twith San Joaquin <br /> PP applicmadeation and/or install the work herein described. This app <br /> ' County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCAT ON '� Q <br /> _�- ---_ Phone <br /> Owner's Name <br /> k City <br /> Address <br /> License # Phone ' <br /> Contractor's Name <br /> PE OF WORK (Check) : NEW'FWELL /_7 DEEPEN/ / RECONDITION / / DESTRUCTION /? <br /> . PUMPI,INST'ALLATION /X/ PUMP REPAIR /^/ PUMP REPLACEMENT I� ' <br /> other 1 1 <br /> T IT PRIVY <br /> E DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES <br /> PIT OTHER <br /> SEWAGE DISPOSAZ FIELD PUBLIC DOMESTIC WELL <br /> 4 _ PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTENDEAnUSE TYPE OF WELL. <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ~� Drilled Dia. of Well Casing <br /> Domestic/private ---— Driven Gauge of Casing <br /> Domestic/public <br /> � Irrigation Gravel Pack Depth,-of Grout Seal <br /> Te of Grout <br /> Cathodic Protection Rotary Other Information <br /> G Disposal Other <br /> Surface Seal <br /> —Geophysical Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> .PType of`Pump� <br /> PUMP REPLACEMENT; . / / State Work Done <br /> t PUMP .REPAIR: State Work Done r <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> , <br /> Describe Material and Procedure <br /> lLn <br /> rict <br /> I hereby agree to comply with all laws and regulations owelj 'co structieh <br /> on.e San Joaquin LoWithi.ncal aFIFTEENtDAYS <br /> and the State of California pertaining to or regulating <br /> i after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri' t <br /> f 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 /> i PRIOR TO OUTING A FIN INSPECTION. TITLE <br /> SIGNED <br /> D E <br /> W'PL 'I` PLAN 'ON RE FRSE SID <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I DATES g "7 <br /> t APPLICATION ACCEPTED BY <br /> -ADDITIONAL COMMENTS: + FHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY <br /> i DATE INSPECTION BY DATE <br /> 3/76 2M <br /> G <br /> E H 1426 Rev. 1-74 <br />