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C / SAN JOAQUIN LOCAL HEALTH - <br /> FOF�,OFFICE USE: V 1601 E. DISTRICT <br /> Hazelton Ave. DIST, Stockton, Calif. <br /> 1. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. �Ll <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED 76 -9�v/d <br /> Application is hereby made to the San Joaquin eLoc l Health District Date Issued <br /> and/or install the work heroin described. This application <br /> County Ordinance No. 18b2 and the Rules and Regulations o£ th for a permit to construct <br /> tisofie made a compliance with San District. <br /> JOB ADDRESS AOCATION a San Joaquin Local Health District, <br /> 4l ,C <br /> Owner's Name CENSUS TRACT <br /> Address l Phone <br /> Contractor's Nam City <br /> Licensed Phone L /�7 <br /> TYPE OF WORK (Check): NEW WELL / EEPEN '/� RECONDI <br /> PUMP INSTALLATION TION /f DESTRUCTION %j <br /> Other /% / ' REPAIR /? PumpREPLACEMENT <br /> DISTANCE TO NEAREST: >4gEPTIC TANK _ Z <br /> SEWAGE DISPOSAL FTELD <br /> EWER LINES PIT PRIVY <br /> PROPERTY LINE -- PRIVATE DOMESTICSWEOZ SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL PUBLIC DOMESTIC WELL~ <br /> Industrial �2� cable Tool CONSTRUCTION SPECIFICATIONS _ f <br /> -.-�' -Hostic/private Dia. of Wel1 Excavation <br /> Domestic/public Dfilled Dia. of Well Casing <br /> /public <br /> Irrigation Driven Gauge of Casing <br /> Cathodic Protection ~ Gravel Pack Depth of Grout S <br /> �� <br /> Rotary <br /> seal <br /> Disposal VType of Grout <br /> `Geophysical OtherOther Information _ -- <br /> 7 <br /> Surface Seal Installed B ; <br /> Pte' INSTALLATION: i <br /> Contractor <br /> Type .of Pump ` J <br /> PUMP REPLACEMENT State Work Done <br /> PUMP .REPAIR: <br /> / State Work Done <br /> iES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and relulations of the San .Tun ui <br />.nd the State of California pertaining to,`or regu "ting well 'construction. With <br /> fter completion of my work on a new well, I re" ', ish the San Joaquin n Local Health District <br />'ELL DRILLERS REPORT of the well and notify them°be'€ore puthe . Joa ie FIFTEEN DAYS <br /> ELL mationDRILLS is true to tthe well and quirt Local Health District a <br />�IOR TO y_knowledge and belief. 0. g ell in .use.... The above <br /> GRO I AND A FI INSPECTION. z WILL CALL FOR A GROUT INSPECTION <br /> IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> LASE I FOR DEPARTMENT USE ONLY <br />'P ILIL CATION ACCEPTED B - <br />)DITIONAL COrIl►IENTS: <br /> DATE d <br /> PHASE TT GROUT INSPECTION <br /> fSPECTTONBY . DATE /a PHASE III FINAL INSPBCTI N <br /> INSPECTION BY <br /> E H 1426 <br /> Rev. I-74 - r <br />