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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFF CE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> A APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Permit No. 22�Qf') <br /> Date Issued <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DAT <br /> (Complete <br /> 3� <br /> F <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health <br /> D isrict Joaquin ; <br /> inrcompliancetwithn5an Joaquin <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 and ',the Rules and Regulations °f the San Joaquin Local Health District. <br /> 117-14 3 l �I, o�°t �r CENSUS TRACT <br /> JOB ADDRESS/LOCATION s�_ F ,/ xi <br /> Phone <br /> Owner's Name C <br /> �� °i� <br /> w rt" city <br /> Address <br /> License # �hone 6 - 6 <br /> Contractor's Name i. <br /> ter. <br /> TYPE OF WORK (Check) : NEW WELL '// DEEPEN PUMP REPAIR ON/I pp�(pEREPLACEMENT�1-7 <br /> PUMP INSTALLATION / / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing N <br /> Domestic/private <br /> Domestic/public Driven Gauge of. Casing Cn <br /> /t. <br /> )1,'� Irrigation Gravel Pack Depth of Grout Seal W <br /> T e of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other �_, ' <br /> Surface Seal <br /> Geophysical Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type-.of Pump <br /> k <br /> PUMP REPLACEMENT: /�/ 'state Work Done <br /> State Work Done 3 � mss¢; c ___ ri,�. l✓��[ ta�► ,�; <br /> E PUMP .REPAIR: <br /> Approximate Depth <br /> DESTRUCTION OF WELL: WelliDiameter <br /> _ <br /> Describe Material and ,Procedure <br /> ..- <br /> I hereb a ree to com 1 with all -laws and regulations of the 'San Joaquin Local Health District <br /> Y.. g p` y.° <br /> AYS <br /> and the State of California. pertainingeli °I 'rrailllfurnshating ethecSantJoaquin.LocalhHealthin TDistEEN rict a <br /> after completion of my work on` a new , the -well in use. above <br /> WELL DRILLERS REPORT of the well.and knowledg notify themandfore belieftll WILL CALL FOR A GROL3TeiNSPECTION <br /> I information is true to the best of my <br /> PRIOR TO G OUTING AND A FINAL ; CTI TITLE <br /> SIGNE _ PL ON �+RSg BIDET : <br /> ` r FOR EP TMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III /ANAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY � o DATE ✓ ` •', <br /> INSPECTION BY DATE <br /> 3/76 . 214 <br /> v K. 1426 Rev. 1=74 <br />