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r SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: � 1601 E. Hazeltgn..Av. ,,,:.' Stockton, Calif. <br /> Telephone:::, �209 ,4:66_6781 <br /> APPLICATION FOR WELL CONSTRUCTION _OR PUMP PERMIT Permit No. - � <br /> _ Date Issued <br /> -THIS _�ERMI.T EXP�IRE$�•1��Y,EA&� FROM�.DATE:ISSi1ED,... -; 1 ,ak: <br /> F ! (Gotdplete -Tn Tr pl&cate) .. <br /> Application .is,.hereby t made_to::, ,San Joaquin, Local _tal-th sD!s.triat for_a..permit:to, construct; <br /> and/or install the work•, herein described. made. im: compliance with :San joaqui <br /> County,-,Ordi.nance,,No*. 186Z�aud,=.,the-Rul.e-6= and .Regulations bf:°,t"he, San::FJoaquin; Local,,Health. ,Distri.ct.. <br /> JOB ADDRESS/LOCATION fA�p�cUNSUS.TRACT <br /> Owner'a:Mame <br /> Address �� l City X6_� I <br /> Contractor'"s Name 4% W^ N Licee'nse, #A-0 )-xza Phone.3� � { <br /> TYPE OF WORK (Check) NEW WELL •.DEEPEN / ./ RECONDITION / / bESTRUCTION /—, <br /> PUMP; INSTALLATION PUMP REPAIR /:/ PUMP REPLACEMENT <br /> Other / <br /> DISTANCE NEAREST: SEPTIC TANK . & SEWER LINES. PIT PRIVY 'S <br /> SEWAGE` DISPOSAL9F!,tLD CESSPOOL/SEEPAGE PIT' fa OTHER <br /> PROPERTY; LINE 4 PRIVATE DOSTIC WELL PUBLIC: DOMESTIC WELL ` <br /> ` INTENDED,USE--- TYPE OF -WELL ' j CONSTRUCTION,.SPECIF"ICATIONS, <br /> Industrial Cable `Tool D �a�"' of:We 1 Excavation CS <br /> bomestic/private trilled bia of:Well Casing . 6 <br /> Domestic/public Gauge of Casing <br /> Irrigation „ Gravel Pack ' Depth of Gout Seal ; .� <br /> ;; . ;.. <br /> Cathodic Protection (' Rotary Type` of-Groat <br /> Disposal Ocher " O'ther Info4mati.ori : . <br /> Geophysical �''r iSurfaceSea j�nstal,l.ed B <br /> PUMP INSTALLATION: Contractor { <br /> s Type of .Pump ` H.P. J <br /> PUMP REPLACEMENT: /---State- Work--Done—I1 <br /> t �f <br /> PUMP�REPAIR: /. /" S to t�e Work Done r1; <br /> DEte- <br /> S-TRUCTION. OF. WELL,, Well, Diameter Approximate Depth r <br /> DescribeMaterial and Procedure i <br /> I ;her.ebylagree: to,.comply, with,all' aws and regulations" of the San Joaquin Local Health District <br /> and the State of Califo�pija-!pex'taro ng to or regi7lating, well 'cohstruction. Within FIFTEEN DAYS <br /> after c*pletion of my work on a new well, I will furnish the, S n Joaquin Local Health District a <br /> WELL.DRI-L-LEA-�.S-�,EnR-T--of----the-well:and- noof,y--ii�em-,hefore_putt- ,g__the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL\CALL FOR A GROUT INSPECTION <br /> PRIOR 'TO'`GRO NG' b A `F INSPEC=T/10N. <br /> SIGNED TITLE <br /> D W p1+'T PLAN ON RE-----VERSE SIDE) <br /> . FOR' DEPARTMENT. USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY l DATE - 2 <br /> ADDITIONAL.•C'OM�IENTS4 r <br /> PHASE II GROUT IXSPECV1bN. PHASE ITVFIN_AL. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE "= <br /> 72 "H.1426 Rev. 1-74A. 3/76 2M <br />