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ISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /d--Z- x <br /> (Complete In Triplicate) <br /> ct <br /> Application is hereby made tin described. Thishe San Joaquin oapplicationcal Health Distmade inrict r.co pliancea permit twithnSanuJoaquin <br /> and/or install the work herein d <br /> County Ordinance No.�• 1862 and�the Rules and Re ulations of the San Joaquin Local Health District. t <br /> �, CENSUS TRACT <br /> JOB ADDRESS/LOCATION 3 / <br /> Phone#6 <br /> Owner's Name <br /> City <br /> Address <br /> `. License ?,I/Phone <br /> Contractor's Name <br /> i •} t it <br /> PE OF WORK (Check) : NEW WELDEEPEN/ / RECONDITION' <br /> / DESTRUCTION <br /> /� <br /> TY j L/PUMP INSTALLATION ../ / P REPAIR /�/ PUMP REPLACEMENTr--1-7 <br /> Other i/ / <br /> a— <br /> DISTANCE TO NEAREST: i SEPTIC'TANK= SEWER LINES PIT PRIVY <br /> € SEWAGEdDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USEEOF <br /> # TY LINE WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dof Well Excava <br /> industrial <br /> tion <br /> r,a <br /> Drilled Dia. of Well Casing <br /> i �: Domestic/Private Driven Gauge of Casing o_ <br /> Domestic/public , <br /> Irrigation -} Gravel Pack Depth of Grout .Seal <br /> , <br /> CathodicyProtection Rotary Type of Grout <br /> Other Information ' �l <br /> � iOther <br /> Disposal! Surface Seal Installed B : <br /> Geophysical �} <br /> PUMP INSTALLATION: Contractor ` H.P. <br /> Type of"Pump <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / State Work Done ' <br /> r/'s i A <br /> { �., •. Approximate�Ilepth �� <br /> DE5•TRUCTION OF WELL: :.�Wel1,Diameter- <br /> Describe Material and Procedure <br /> I hereby agree-4 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- -W3th n�IFTEENTDAYS <br /> after completiono:(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 GROUT NG AND A FINAL I PE ION. TITLE <br /> SIGNED <br /> DRAW pL T'PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> e /O-'f <br /> PHASE I g DAT <br /> ' APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY / DATE o - J1 <br /> INSPECTION BY �,�i, '.I DATE /� , <br /> r Y <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />