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ICT <br /> 1° SAN JOAQUIN LOCAL HEALTH ont Calif. <br /> FO ---- USE: 1601 E. 'Hazelton Ave. , Stocktton, / <br /> Telephone: (209) 466-6781 Permit No. 7L` <br /> APPLICATION FOR, WELL` CONSTRICTION OR PUNA' PERMIT 7.5- YSW <br /> FROM DATE ISSUED Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR ' <br /> (Complete In Triplicate) permit to.constxuct <br /> application is made in compliance with San Joaquin: <br /> Application ie hereby made to the Saibed�.quThisor�gp health District °r a Local Health District. <br /> lip <br /> and/or install the work herein descr lations o£ the San 3oaqu n ! s <br /> County Ordinance Iia. 1862 and the Rules and <br /> ji CENSUS TRACT <br /> ,SOB *DDMSS/LOCATION <br /> Phone ' <br /> Owner's Name <br /> I � City <br />` II ��� E <br /> t Address Phone <br /> License <br /> Contractor's Name <br /> € ii WELL DEEPENS /� RECONDITION /�T DESTRUCTION JT <br /> TYPE OF WORK (Check) . NEW P REPAIR /� PUAP REPLACEMENT <br /> �T <br /> PUMP INSTAL . . . . . <br /> if0ther { / <br /> ' SEWER LINES PIT PRIVY <br /> OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK ,,.,�. CESSPOOL/SEEPAGE PIT D <br /> SEWAGE DISPOSI�L FIELD �,. /PUBLIC DOMESTIC WELL <br /> PROPERTY LINE``_RIVATL DOMESTIC WEL, RUCTION SPECIFICATIONS x. <br /> III USE l 'TYPE OF WELL <br /> TN <br /> Cable Tool Dia. of Well Excavation d <br /> s Industrial Dia. of Well Casing <br /> DrilledIF <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public:il De th of Grout Seal <br /> Gravel Pack P <br /> Irrigation Rotary T YP..e.. of Grout` <br /> Cathodic Protection Other- Information <br /> 4 Others . <br /> k _Disposal -�---- Surface Seal Installed B C <br /> Geophysical ` 3 <br /> PUMP INSTALLATION: Contractor- w F H.P. - <br /> 1 Type .of Pup <br /> PUMP REPLACEMENT: i;° State Work Done ' <br /> PUMP '.REPAIR: / <br /> State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: sI . Well Diameter <br /> Describe Material and Procedure <br /> _s <br /> San <br /> rict <br /> I hereby agree-to colmply.with••all laws•.ax�d ':xegulata n °We i�co struction.LoWithinaFIFTEENlth tDAYS <br /> and the State of California pertaining to or regulating <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL'DRILLERS REPORT,'' of the well and notify them before putting.the..we11 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 GROUTING AND A FINAL INSPECT IO TLE <br /> AGNED P PL ON REVERSE SIDE <br /> }� FOR DE TMENT USE ONLY ,�� �7 <br /> PHASE I - DATE���- /1 <br /> APPLICATION' ACCEPTED BY <br /> ADDITIONAL ,COMMENTS: PHASE III FINAL INSPECTIO <br /> P SE II. G 0 INSPECTIO DATE {J - 7 <br /> `INSPECTION BY r1 DATE Z INSPECTION BY <br /> Uli,a u 1L9N pv, 1-74 <br />