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SAN JOAQUIN LOCAL HEALTH: DI <br /> F� O�'FICE USE: � STRICT <br /> j — 1601 E. Hazelton Ave; , Stockton, Calif. <br /> i - <br /> P <br /> APPLICATTON�ORWELL.CONSTRUCTION OR PUMP PERMIT Permit No. g _sgalb <br /> THIS PERMITEXPIRES 1 YEAR <br /> E FROM DATE ISSUED Date Issued <br /> ' Complete In Triplicate) <br /> Application is hereby Made to the San Joaquin' Local Health District for a permit to construct <br /> i and/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health .Distr ct. <br /> JOB ADDRESS/LOCATION ict <br /> s ' . ji III <br /> CENSUS TRACT <br /> 110 <br /> Owner's Name . J,e `�� <br /> Phone - <br /> Address <br /> hone -Address � Y � � . <br /> city <br /> Contractor's Name 11,11 <br /> License #I_&22L hone <br /> TYPE OF WORMCheck) : <br /> C NEW WELL LL DEEPEN-17 N 'r- RECONDITION 17 DESTRUCTION f <br /> PUMP INSTALLATION PUMP REPAIR"/� PUMP REPLACEML�NT <br /> Other %/ � <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOSAL FIEEWER LINES PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS ; <br /> _ Domestic/private ---- Cable Tan1 Dia. of Well Excavation <br /> Domestic Drilled Dia. Of Well Casing <br /> Domestic/public ...r___ Driven <br /> Irrigation Gravel Pack Gauge of Casing <br /> �,� Depth of Grout Seal <br /> _ Cathodic Protection —�_ Rotary Type of Grout <br /> - `Disposal V _ Other <br /> Geophysical — Other Information <br /> Surface Seal Installed B <br /> PUMP TNSTALLATION: Contractor ` r <br /> *pe .of Pump y <br /> H.P. / <br /> PUMP REPLACEMENT: - <br /> 7jff/ State Work Done <br /> ,. <br /> PUMP :REPAIR: �R <br /> / State Work Done �)t <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local H <br /> and the State of California pertaining to or regulating well ''�construction. WithinFI�`TEEN <br /> Health District <br /> After completion of my woAYS <br /> rk 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... <br /> information is true to-the,best-of .The above ' <br />'RIOR TO GROU ING AND A FINAL I .,wledge and belief. I WILL CALL FOR A -1 ROUT INSPECTION <br /> SIGNED TIO <br /> �- , <br /> TITLE A <br /> PLAN ON ERSE SIDE <br />'HASE I FOR DEPARTMENT USE ONLY <br /> IRICATION' ACCEPTED BY <br /> IDDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III INSPECTION <br /> NSPECTION <br /> NSPECTION BY DATE INSPECTION BY <br /> r <br /> _ - .. .. DATE <br /> E H 1426- Rev. 1-74 " <br /> L I- <br /> I <br />