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s <br /> FLSOJOAQUIN LOCAL HEALTH DISTRICT <br /> rDR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, -Calif- <br /> Telephone: <br /> tockton, CalifTelephone: (209) 466-6781 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X11 y� <br /> 77- 710 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1�?licntion is hereby mode to the Snn JoapquineLocs.n Triplicate) <br /> t�id/ar inatull the work herein described. This <br /> Health District for a permit to construct <br /> Joain <br /> :—inty Ordinance No. 1862 and the Rules and TRegulations tofnthe Is SaneJoaquinpLocal eHealthwithSan District. <br /> 113 ADDRESS ON" >z -- <br /> f CENSUS TRACT <br /> ; r hr.er's Name y•� f ��.v�. <br /> � - Phone <br /> Adress <br /> a ' � City <br /> .-,tractor's �1,• ,�� -� <br /> r s Name (� V 'i:./ .1 <br /> S License/�jphone '�•�! <br /> -- a = .... <br /> IF OF WORK (Check) : NEW WELL/ N <br /> DEEPE�/7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION � PUMP REPAIR/_7 PUMP REPLACEMENT /? <br /> Other. <br /> L TANCE TO NEAREST: SEPTIC TANK ,- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LIW�QPRIVATE DOMESTIC WELL .� PUBLIC DOMESTIC WELL - \, <br />-k . INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �, \ <br /> Z , Domestic/public <br /> Irrigation Driven Gauge of Casing � <br /> Gravel Pack Depth of Grout Seal. <br />�. Cathodic Protection Rotary Type of Grout <br />_� �Disposal Other yp <br /> Geophysical --�^, Other Information <br /> SLUrf ace Seal Installed B \` <br /> JFINSTALLATION: Contractor <br /> Type of Pump H.P. <br /> JP' REPLACEMENT: /% State Work Done <br /> 0 <br /> JM' :REPAIR: <br />----�.— / / State Work Done •- <br /> 177RUCTION OF WELL: Well Diameter r�v . <br /> Approximate Depth r <br /> Describe Material and Procedure <br />�':reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> L( the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br />'ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />;?-, DRILLERS REPORT of the well and notify them before putting the.-well in use.. The above <br /> ,rmation is true to the best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GROUTING AND A FINAL INSPECT <br /> nR <br /> PLO PLAN ON REVERSE SIDE <br /> PEI FOR D. PARTMENT USE ONLY <br /> (� <br /> F' +ICATION ACCEPTED BY <br /> ULTIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION :-ECTION BY DATE r INSPECTION BY Y ' <br /> DATE - . t <br />�B 1426 <br />