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FOS rOFFICE UST's JOAQUIN LOCAL HEALTH DISTRIC -._..-_.. <br /> Hazelton Ave. , Stockton, Ca <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PE <br /> RMIT P 61 M-56, <br /> THIS PERMIT EXPIRES 1 R. Data <br /> .FROM DATE ISSUERt�� <br /> YEA <br /> Issued <br /> To <br /> ApPlicQtion is hereby made to the San(vaq in Local rHealth District <br /> and/or install the work herein described. This application is made incomplianceto Construct <br />' County Ordinance No. 18f2 and the Rules an San Joaquin <br /> gulations of ,the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ti CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address ,`;.. <br /> Contractor's Name l <br /> 04 License :D/dhone c� <br /> y � <br /> TYPE OF WORK (Check): NEW WELL LZ'DEEPCONDITION <br /> PUMP INSTALLATION 17 DESTRUCTION /7 <br /> Other 27. . REPAIR /�_PUMP REPLACEMENT r 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK�&� <br /> SEWAGE DISPOSAL EWER L�NES � PIT PRIVY <br /> M=ESS OP OL/SEEPAGE PI OAR"'t ` <br /> INTPROPERTY LINE -- PRIpATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ENDED USE TYPE;OF WELL <br /> Industrial CONSTRUCTION SPECIP�TION - <br /> Domestic/publi <br /> mesric _� Caile Tool Dia, of Well ExcavationQ <br />;.�-:.1�'$� /Private � Drilled Dia. of Well Casing Sc Driven p <br /> Irrigation -'"--- Gauge of Casing ^ <br /> --- Gravel Pack __- - <br /> _�ep_fh_of_Groutal - --- <br /> Cathodic Pxotectiox: -- � <br /> !,�a'tary � �rc�----- <br /> Disposal - - Other ' TYpa, of Grout I° <br /> .. Geophysical _,., , Other InfoLinat on <br /> ' I <br /> ace Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of f <br /> 'UMP REPLACEMENT: State Work Done <br /> PUMP '.REPAIR: , <br /> /7 State WoI Dome <br /> i <br /> ES TRUCTION OF WELL: 'Well Diameter r <br /> Describe Materpial and Procedure Approximate Depth <br /> ` - <br /> Y g p y p _. _...-_..._._ <br /> hereby agree to comp 1 with all laws and11!g4lations of the San Joaquin <br /> and the State of California ertainin to or'�re u $ i well construction. <br /> Local' Health District <br /> after completion of my work on a new w�e11, I will�fut�nish the San Joaquin Lowalhin FI EEN DAYS <br /> WELL DR R5 REPORT o ' the well and notify them before putting..the..wel in District a <br /> informat true to the-bee of $. The above <br />'RIOR TO G T G AND A FINAL edge and belief. I WILL CALL AOR. GROUT INSPECTION <br /> SIGNED N O _._-._.. . <br /> :•,. <br /> TITLE • d r X71 ri <br /> (DRA T PLAN ON REVERSE fLSID <br /> FOR- DE <br /> [ENT'`; E <ONLY <br /> IPPLT TED. BY <br /> IDDITIONAL COMMENTS: - � - <br /> DATE �J �I 7� <br /> TI T INSPECTI N P iII/ EC <br /> INSPECTION BY ` DATE � . N NSPTIINSPECTION BY <br /> SATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 IM <br />