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SAN �� �`QUIN LOCAL..HEALTH DISTRICT, �.,� <br /> FC3 y � E USE: ' 1601 E..?Frazeiton Ave. , Stockton, Calif. <br /> Telephone:. (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete. In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health: District for a permit-to cgnatruct <br /> and/or install the work herein described: This application is made in compliance with Sa[}, Joaquin <br />'rCounty Ordinance. No. 1862 and the Rules and Regula ions of' the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION d / J � 1 C9�f CENSUS TiiACT <br />,Owner's Name /'/� T � C}'. 9� r T'Ji �� Phone <br />,.Aaaress City .� <br /> N <br /> ct <br /> Contraor's Name i License <br /> . <br /> E <br /> kTYPE of WORK (Check)': . NEW WELL /DEEPEN /7/- RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR ../ / .PUMP REPLACEMENT J�' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES PIT PRIVY --1 <br /> k. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERw .� <br /> PROPERTY LINE .» PRIVATE DOMESTIC WELL '— 'PUBLIC DOMESTIC WELL <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS- . �. <br /> •Indus trial .: a <br /> C ble Tool Dia, of ,Well Excavation ., <br /> �/ Domestic/private DrilledDia. of`Well Casing / <br /> Domestic/public' . Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea ' - <br /> Cathodic Protection ✓RotaryType of -Grout <br /> Disposal . Other Other' Information <br /> Geophysical: Surface ,-Seal Installed By. Z <br />-'PUMP INSTALLATION: Contractor <br /> Type of .Pump 01 H'P,' _ <br /> ISI , ,i •, <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP -REPAIR: / / State Work Done , <br /> DESTRUCTION OF WELL: Well Diemeter A" imate DeAfth pro <br /> De ib"a fte a1 Procedure <br /> I1 hereby -agree to comply.with (J g lation1 of the San Joaquin Local Health istri t <br /> and, the State of California, pertaining,•toi_or `regulating, well '•construction. Within FIFTEEN DAYS <br /> after cou�pletion 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 trae to the best of my-knowledge and belief. I'WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO =GROUTING ANDA FINAL INSPECTION. .` <br /> SIGNED'. TITLE <br /> DRAW; PLOT PLAN ON REVERSE SIDE) <br />' FOR DEPARTMENT USEzjONLY ,, <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY zz <br /> DATE ,2 - <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHAS I/F NAL INSPECTION <br /> INSPECTION BY DATE, :INS PgCTION BY DAT7`0:_-3-79 <br /> C`.J Y'9V�P.��Z��Sr�j� �[�f�• C�^!�.r ��.��/L'.z�� 1 ���'i/�i� `�.-� l���.:�-r �,... % V1 t.��; "� .S f4„b,` �n <br />�. 'E H 1426 / ''Rev. 1-74 -- <br />