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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F` 1601 E. Hazelton Ave. , <br /> Stockton, Calif. <br /> FOg�jOFFICE USE: (209) 466-6181 <br /> I Telephones PERMIT Permit No. T�--��� <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP pate Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j <br /> (CompletTr <br /> e in iplicate) permit to construct <br /> is wade in: compliance with San Joaquin': <br /> alth <br /> Application is hereby made to�the San 3 . This oapplicati.on District for a p cal 'Health District* <br /> and/or. the work herein describe <br /> Ordinance No. :1862 and; the Ru s and ReSu3ations of the San Joaquin o <br /> County i CENSUS TRACT <br /> JOB ADDRESS/LOCATIUI Phone) { �' <br />` <br /> owner's Name City <br /> :. <br /> Address r;1 License e. Phone -2 <br /> contractor's Name 41 <br /> DEEPER '/� RECONDITION /_7 DESTRUCTION <br /> I f7 0 <br /> I TYPE OF WORK (Check): NEW WELL /� per, REPAIR /� <br /> PUMP REPLACEMENT <br /> p� ;NSTALLATION / <br /> other, /� <br /> SEWER LINES �_ PIT PRIVY OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK. CES <br /> SPOOL/SEEPAGE PIT �— <br /> SEWAGE DISPOSAL FIELD �,�� PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> k Industrial Drilled Dia. of Well Casing <br /> Domestic/private .��_ Gauge of Casing <br /> tiublic - Driven Depth <br /> of Grout Seal <br /> -"�- <br /> Domestic/public Gravel pack p <br /> Irrigation --� Rotary Type of Grout <br /> Cathodic Protection t �-- Other _._ Other Information <br /> Disposal M1 --- surface Sea! Installed B <br /> _Geophysical _ <br /> PUmp INSTALLATION% Contractor S.P. <br /> Type of Pump <br /> �I,,E�: State Work Done <br /> PUMP REPLA <br /> PUNii? '.REPAIR: /7 State Work Done <br /> Approximate Depth <br /> ES TRUCTTON OF WELL: Well <br /> Describe Material and Procedure <br /> i <br /> i <br /> hereby agree to comply with all laws and re$uiations of the San Joaquin LoWithinaFIFTEENtDAYS <br /> ` I y to or regulating well construction. <br /> and the State of California pertaining uin Local Health District <br /> after completion of my work on a new well, I hemwilbefore puttingfurnish the San well in.use.. The above <br /> WELL DRILLERS REPORT of :the well and notify them <br /> information is true to the-best of- my-knowledge <br /> and belief. TWILL <br /> CMX OR AGROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE M�,_ <br /> � <br /> SIGNED -' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY ;NSPECTION <br /> ADDITIONAL C014KMS: PHAS I ATE <br /> } PRASE IT GROUT INSPECTION INSPECTION BY �.- <br /> INSPECTION BY DATE <br /> 1-74 2H <br /> � 1 R 1426 Rev. 1-74 <br />