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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued Z324 <br /> M.. (Complete In Triplicate) per to construct a <br /> Application is herb made to:�the San cxibed�quin Thisocal Healthapplicati.on istrict made inrco compliance with Sans Joaquin <br /> and/or install the work herein des <br /> Count Ordinance No. 18b2 and the Rules and Regulations of the San Joaquin Local Health Ditr ct. <br /> County roCr <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION / Phone <br /> Owner's Name /er! - - - - _- <br /> City <br /> Address <br /> �� 'Tone <br /> Contractor's Name <br /> dRECONDITION j I DESTRUCTION /-7 <br /> TYPE OF WORK (Check) , NEW�G1ELL / DEEPEN / puMp REPLACEMENT /� <br /> PUMP .INSTALLATION PUMP REPAIR <br /> Other 1 I <br /> SEWER ;LINES PZT PRIVX i <br /> DISTANCE TO NEAREST: SEPTIC TANK_ CESSPOOL/SEEPAGE PITS OTHER <br /> SEWAGE DISP6SAL FIELD <br /> PROPERTY LINE/U DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> E OF WELL x CONSTRUCTION SPECIFICATIONS <br /> INTENDED. USE ;TYP \ <br /> ``�,� t Cable T0011— Dia. of Well Excavation <br /> Industrial. Dia.; of Well Casing <br /> _ ^ <br /> Domestic/private,',, ��� Drilled F O <br /> Drivensti Gauge of Casing � <br /> Domestic/public , Depth of Grout Seal <br /> Irrigation Gravel Pack p <br /> Rotar Type of Grout <br /> Cathodic Protection Othery��other Information <br /> Disposal , � 5urface Seal Installed B <br /> Geophysical <br /> 4 <br /> PUMP INSTALLATION: Contractor) H.P, <br /> Type of pump � <br /> ,t <br /> PUMP REPLACEMENT• /�/y State Work Dane44, <br /> ( PUMP .REPAIR: / / Sta.te(Work "Done <br /> Approximate Depth , <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe,.Material and Pzacedute <br /> cal <br /> rict <br /> San <br /> 1 hereby agree to comply with all laws and regulationsi ��.construction.Joaquin LoWithFinaFIFTEENtDAYS <br /> I d g regulating and the State of California pertaining to or reg g <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT the well and notify <br /> andore beiief. <br /> ? the -well In <br /> information is <br /> ylthe <br /> fputting WILL CALL FOR AeGROUTeINSPECTION <br /> tr o e my g <br /> PRIOR TO GROUTI AND A F AL NSP CTI TITLE <br /> e SIGNED DRAW pi 'T PLAN ON RE FRSE SIDE) ' <br /> E. OR DEP MENT USE ONLY <br /> ` PHASE I - �L DATE -� <br /> APPLICATION ACCEPT Y' <br /> ADDITIONAL COMMENTS: PHAS I I/FI AL INSPECTION <br /> PHASE II GROUT INSPECTIONo` INSPECTION B DATE <br /> INSPECTDATE D 7 <br /> ION BY <br /> N 3/76 2.M <br /> ( v <br /> 11179 Aov_ 1-74 <br />