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SAN JOAQUIN LOCAL HEALTH DISTRICT t..A <br /> FOF:,OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> ~1,3300 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issue Id 3-_76 <br /> (Complete In 'Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. Tis application is ma e 'in compliance with San Joaquin <br /> C ty Ordinance No« a d the Rugs an u atline of t S Joaquin Local Health District. <br /> '33 P <br />� B ADDRE S/LOCA ION t �` � CENSUS TRACT 4r#� <br /> ° Phone Q <br /> Owner's Name <br /> Q City <br /> Address �- <br /> Contractor's Name <br /> iidense + Phon <br /> TYPE OF WORK (Check): NEW WELL/&T—DEEPEN -/ 7 RECONDITION f DESTRUCTION fT <br /> PUMP INSTALLATION/ pUMP ,R.EPAIR /� PUMP REPLACEMENT �I <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (." <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial L Cable Tool Dia. of Well Excavation <br /> mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing j Pr0 <br /> :.Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Surface <br /> Information' <br /> Geophysical Surf ace Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' 31 A01 <br /> PUMP REPLACEMENT: ."• / State' Work Done - - <br /> PUMP ,,REPAIR:' / / State Work Dane <br /> I]ES4RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i'l hereby agree with all laws and regulons of the San Joaquin Local Health District <br /> g to comply p y regulations <br /> land the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I•will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well. in use.. . 'The above <br /> information is true to the,bes t of my..knowledge and belief. I WILL CALL FOR-A-GROUT INSPECTION <br /> #PRIOR TO GROUT31NG ' D A FINAL INSPECTW <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , f / J <br /> APPLICATION ACCEPTEDI BY <br /> DATE/ `7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR INSPECTION / PHASE III F INSPECTI N <br /> INSPECTION BY DATE - Z B/ �, INSPECTION BY DATE 7 <br />