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FOF.OF , CE USE: ,v SAN .�OAQUIN LOCAL HEALTH.DISTRICT <br /> * -• 1601 E. Hazelton Ave.; Stockton, Calif. <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED Date Issued `�- r,5-` 7 <br /> . � (Complete In Triplicat <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> and/or install the work herein described. This permit to construct <br /> application is made in compliance with San Joaquin . <br /> County Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> 6. tii CENSUS TRACT , <br /> Owner's Name <br /> d Phone <br /> Address f o a <br /> city . <br /> Contractor's Name <br /> y License 0yy�Phone =76. <br /> TYPE OF WORK (Check).: NEW WELL / /. DEEPEN ~_ a <br /> /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /}q+ PUMPREPLACEMENT s <br /> Other % f <br /> .k . <br /> DISTANCE TO NEAREST: SEPTIC TANK ` <br /> SEWER LINES _ • PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY 'LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTICOTHER <br /> INTENDED USE TYPE OF WELL . , <br /> _ Industrial "' CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven , <br /> Irrigation Gauge of Casing <br /> GravelPack Depth of Grout Seal. 0 <br /> Cathodic Protection Rotary Type of Grout <br />-Disposal Other Other Information <br /> Geophysical Surface Seal .Installed By: <br />'UMP INSTALLATION: Contractor 'mow <br /> Type of Pump <br /> c� <br /> II.P. <br />`UMP REPLACEMENT: ~ <br /> State Work Done � <br />'UMP'•.REPAIR: /k/ State Work Done {f ` <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ad the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> Eter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the .well. in use. The above <br /> aformation is true to the.-best -of my- riow d Band-belief. , I WILL CALL FOR A GROUT INSPECTION <br /> JOR TO GROUTING AND A FINAL INSPE6I0 <br />[GNED <br /> ITLE <br /> D PLOT P ' - ON RSE SIDa *'��'-�'-- <br /> LASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br /> IDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> ISPECTION BY /1/ - - DATE INSPECTION BY <br /> DQE . 2 a . <br /> 1 <br /> E H 1426 Rev. 1-74 1177 ",q F <br />