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SAN JOAQUIN LOCAL 1IFALTkTDISTRICT <br /> r <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. 5� ; <br /> THIS PERMIT. EXPIRES 1`YEAR FROM DATE.'ISSUED <br /> Dare Issued ��-7� <br /> 1..�I .(Complete In Triplicate) <br /> Application is hereby made to. the cri ed. Thisapplicationical health stmade inrcompliancepermit twith San Joaquin <br /> and/or install the work herein described. P <br /> Ordinance No. 1862 and}-the Rules .and Regulations of the San Joaquin Local Health District. <br /> County �i <br /> AV CENSUS TRACT ' <br /> JOB ADDRESS/LOCATIONe <br /> 36q g <br /> � ..C,. ... Phone ' <br /> Owner's Name <br /> city <br /> 9f <br /> Address s . <br /> -- License # Phone <br /> contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL JI DEEPEN I l <br /> RECONDITION /-T DESTRUCTION /7 <br /> 07 <br /> LT <br /> PUMP INSTALLATION �/ / PUME REPAIR I I I' REPLACEMENT <br /> other <br /> V SEWER LINES IT PRIVY _ <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> I SEWAGE DISPOSAL FIELD �_-.- <br /> ' CONSTRUCTION SPECIFICATIONS v <br /> INTENDED USE 'TYPE OF WELL <br /> Cable Tool Dia. of Well. Excavation Z <br /> G Industrial Dia. of Well Casing <br /> Domestic/Private EK Drivend Gauge of Casing �- <br /> Domestic/public _ — <br /> F Irrigation Gravel Pack Depth of Grout Seal <br /> S' <br /> Rotary Type of Grout <br /> I Other <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type' of Pump ^- •.dr <br /> / State Work Done <br /> i PUMP REPLACEMENT: <br /> PUMP REPAIR: / State Work Done <br /> Approximate Depth _ <br /> 4 DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> theSan oaqui-n at <br /> rict <br /> I hereby agree to comply with all laws and regulations of coconstruction. WithinFIFTEENDAYS <br /> and the State of California pertaining to or regulating wellJoaquin Local Health District a <br /> E after completion of my,work on a new well, I will furnish the San the <br /> WELL DRILLERS REPORT of the well and notify <br /> ethem <br /> before <br /> nd belieftting the well in use° The above <br /> ! information tr4eo best of my g <br /> TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY r� <br /> PHASE I DATE��d ��l <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE II/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE/o�' ��_ <br /> INSPECTION BY i DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 ' <br />