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12 SAN JOA <br /> LOCAL HEALTH DISTRICT _ <br /> FOF OFFICE 'USE: <br /> E. Hazelton Ave. , Stockton, Calif. / <br /> Telephone: (209) 466 6781 <br /> "' <br /> Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION-OR'PUMP PERMIT ---_----- �/ <br /> THIS PERMIT EXPIRES l YEAR FROM:A. TE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) permit <br /> Application is hereby;made- to the San <br /> a Joquin Loc.his 1 Hea16 Districtmade for <br /> compliancetwithnSanuJoaquin <br /> and/or install the work herein described. <br /> County Ordinance No.yi1862 and- the Rules and Regulations of the San Joaquin Local Health District. ` <br /> r� OX / t <br /> I r CENSUS TRACT <br /> JOB ADDRESS' <br /> Phone <br /> Owner's Name <br /> City <br /> Address f <br /> License ;-7e"Phone <br /> k Contractor's Name <br /> E <br /> W WELL DEEPEN RECONDITION / I DESTRUCTION <br /> TYPE OF WORK (Check} : NEW <br /> PUMP I _-A LATION / PUMP REPAIR. / / PUMP REPLACEMENT I <br /> Other <br /> SEWER LINES /-PIT 'PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK � .� <br /> SEWAGE DISPOSAL F ELD �'� CESSPOOL/SEEPAGE PIT � � .{$THER <br /> -- ---PROPERTY-I IN -0IVATE DONIE5TIC 4JELI/�_�` PTJBLIC DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WEZL �. <br /> Industrial Cable Tool Dia. Well Excavation C <br /> Domestic/private . T Drilled-- n Dia. of We11TCasing <br /> >' <br /> :Domestic/public Driv�_en Gauge of Casing -1 ti• .. � <br /> irrigation Gravel Pack Depth of GroutjSe 1-� <br /> _ Rotar Type of Grout <br /> Cathodic Protection y <br /> Disposal Other Other information <br /> t <br /> Geophysical Surface Seal1 <br /> , n-stalled B <br /> PUMP- INSTALLATION: Contractor H.P. <br /> Type of 'Pump _. <br /> State Work Done <br /> FUM`' REPLACEMENT: / / <br /> PUMP .REPAIR: <br /> State Work Done <br /> .` / / <br /> IDES-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby agree- to cotriply with all laws and regulations'of-the San Joaquin Local Health District <br /> and the State` of California pertaining to or regulating well-'con'struction. Within FIFTEEN DAYS <br /> i after completion of my Mork on a new well, I will furnish the San Joaquin Local Health District <br /> `r WELL DRILLERS REPORT of- tle. well and notify them before putting the, well in use. The above <br /> information is true ,to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRI'Ok TO GROUTING AND''A FINAL INSPECTIO TITLE <br /> SIGNED <br /> AN ON REVERSE SIDE) <br /> FOR- PARTMENT USE ONLY <br /> PHASE I _...DATE. <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: P / IN INSPECTIO 40 <br /> P E OUT INSPECTIO INSPECTION BY E <br /> INSPECTION BY DATE 2 0 !� <br /> 01.77 _ 2�rtp <br />