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�d . 16 c/o <br /> 0.9 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�,OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> a APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. MOO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ,?-7- <br /> (Complete <br /> ssued •? 7(Complete In Triplicate) <br /> P ) <br /> Application is hereby made to the San Joaquin Local Health Distract for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San--Joaquin Local Health District. <br /> Ir <br /> JOB ADDRESS/LOCATION ��'�� �� -_�)p C-L,132,, a e r CENSUS TRACT <br /> Owner's Name ,� d , Phone ' <br /> Address '1 City _ <br /> Contractor's Name Ge u License #/ 7�2. Phone V44-2­26,'J� <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN'/_ --RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION f_1 PUMP REPAIR -/ PUMP REPLACEMENT /7 <br /> Other <br />!I 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 (A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing - R' <br /> Domestic/public Driven Gauge of Casing �1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr- y -,Type Rotar T e of Grout <br /> -- � <br /> -Disposal p .. Other � Other Information.' <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor ® �� <br /> t Type. of Pump . .., . - H.P. / <br /> PUMP REPLACEMENT / / State Work Done a <br /> PUMP :REPAIR; / J State Work Done <br /> ILDES;TRUCTION OF .WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure x <br /> PP P <br /> I hereby agree 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'cons.truction. Within FIFTEEN DAYS <br />': after completion of 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.know d nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND;A VINAL INS E 0 . <br /> SIGNED TITLE <br /> PLAN ONVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 4APPLICATION ACCEPTED BY DATE - <br />( ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />! INSPECTION BY DATE INSPECTION BY A.Iv. DATE - <br /> 1� <br /> E"B 1426 - Rev: 1-74 f4/75 <br /> 2M <br />