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JOAQUTN LOCAL HEALTH DISTRIC j <br /> FOH OFF CE USE: 16C E. Hazelton Ave. , Stockton, Ca" 4A. //'! <br /> J %-INTelephone : (209) 456--6781 <br /> 9madeto <br /> TION FOR WELL CONSTRUCTION OR PUMP PERI ermit No. <br /> H PERMIT EXPIRES l YEAR FROM DATE ISSUED D to Isst:ed r� 7� <br /> (Complete In Triplicate) <br /> oplication is here y the San Joaquin Local Health District for a permit to construct <br /> ad/or install the work herein described. This application is made in compliance with San Joaqui <br /> ounty Ordinance No. 1862 and the Rules and Regulaticns of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATIONrnQ E _ CENSUS TRACT <br /> janer I s Name T I rack�t n _ Phone <br /> jdress <br /> q _ city <br /> cntractor' s Name �� License �f _Q�1Phoi�e <br /> YPE OF WORK (Check) : NEW WELLDEEPEN / / RECOYDITION / / DESTRUCTION / 7 L <br /> PUMP INSTALLATION / { PUMP REPAIR j { PUMP REPLACEMENT <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK _aQ� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD =_f CEQSPOOL/°jEEPAGE PITT ifrA, OTHER a <br /> PROPERTY LSNE/JPRIVATE I)0_MESi'I _ id_- L Pi_JSLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _ +" CONSTRUCTION SPECIFICATIONS _ <br /> Industrial Cable Tool Dia. o 4gell Excavation �rr: <br /> Domestic/private Drilled Dir. of Nell Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal -i <br /> Cathodic Protection Rotary Tyne o- Grout - r, <br /> Disposal Other Other Information C2LOCIe <br /> Geophysical Surface Seal Installed By: _ <br /> _'UMP INSTALLATION: Contractor _ .. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done -- -�� <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> lrr Describe Material and Procedure <br /> . <br /> j hereby agree to comply with a laws and egulations of the San Joaquin Lo al Health District <br /> end the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work`.-bd::a:''aew well, I will furnish the San Joaquin Local Health District a <br /> a -1ELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> _nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. �7 <br /> SIGNED - ` . TITLE <br /> { td P 10 <br /> OT PLAN ON REVERSE SIDE) <br /> . FOR DEPARTMENT USE ONLY <br /> 'RASE I DA -Z-AS/7 <br /> y ', APPLICATION dgPTED BY TE <br /> %DDITIONAL COMI-E NTS to J, a <br /> ' PHASE .II GROU _INSP ETION PHASE III F N1 1 I146PECTION <br /> rNSPECTION BY DATE , INSPECTION BY DATE <br /> /7 _ 2M <br /> E H 1426 Rev- 1-74 <br />