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—FOP--'-OFFICE USE SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � 1601 E. Hazelton Ave .. • <br /> . , •Stockton, Calif. <br /> Telephone: (209) 466=6781w, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP.pERMIT Permit No. <br /> THIS`PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <br /> ApplicafS 7 7 <br /> tion is (Complete made to the San Joaquin Local Health District-fora permit <br /> and/or install the work herein described. This application is made in compliance 1 <br /> County Ordinance No: P mit to construct <br /> 1862 and the Rul a P lance with San Joaquin <br /> egulations of te San Joaquin Local Health District. <br /> JOB ADDRESS/LOC <br /> CENSUS TRACT <br /> Owner's Name, <br /> Address Phone <br /> �. Cit U <br /> Contractor's Name <br /> ' License # ` Phone ' <br /> TYPE OF WORK (Check) :. NEW WELL <br /> / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION ZR— REPAIR / / PUMp`REPLACEMENT /_7 <br /> Other <br />'DIANEAREST: <br /> STNCE TO SEPTIC TANK <br /> SEWER LANES PIT PRIVY vl <br /> SEWAGE DISPOSAL FIELD - CESS OP OL/SEEPAGE PIT Uj <br /> PROPERTY LINE -,,PRIVATE OTHER <br /> INTENDED .USE E DOMESTIC WELL PUBLIC DOMESTIC WELI, <br /> TYPE OF WELL . �- CONSTRUCTION SP$CIFIC�ATI_ <br /> Industrial. <br /> Domestic Cable Tool -Dia. of Well Excavation , <br /> /private Drilled <br /> Domestic/public Dia. of Well.,Casing <br /> Irrigation' Driven Gauge of Casing <br /> Cathodic ProtectionGravel Pack Depth of Grout` Seal <br /> Disposal V Rotary TypeiInform bnof Grout <br /> ' y4ther .F Other il = _ <br /> Geophysical � �?�. --�.�. -•---.�--:_ <br /> . Surface Seal Installed <br /> PUMP INSTALLATION: <br /> Contractor. r--� <br /> of Pump <br /> Type H.F. F: <br /> / <br /> PUMP REPLACEMENT. '���• <br /> S �tate=Work Done <br /> PUMP .REPAIR't <br /> / / State Work Done - <br />)ES•TRUCTION OF WELL: Well Diameter <br /> Describe ,Material and Procedure Approximate Depth <br /> hereby agree 'to com 1 with al1- <br /> Laws and regulations of the San ,Toaquin Local Health istr , <br /> end the State .of California pertaining to or regulating we11 'constructio <br />.fter completion of my work on a new well, I will furnish the San Joaquin Local Health Di ict <br />►ELL DRILLERS REPORT of the well and notify them before u n' Within FIFTEEN RAYS <br /> nfarmation is true to the .best of m knowled a and belief. strict .. <br /> p ting the.-well in use. The above <br /> RIOR TO GROUT NG ANDA FINAL INSPECTION. g I WILL CALL FOR A GROUT INSPECTION <br /> IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) = <br /> RASE I FOR DEPARTMENT USE ONLY <br /> PP ICATION ACCEPTED BY ,. <br />)DITIONAL COMMENTS: _ DATE �' I <br /> PHASE II GROUT INSPECTION <br /> 1SPECTION BY DATEPHASE III/FINAL INSPECTION f <br /> INSPECTION BY <br /> /7 DATE <br /> E H 1426 <br /> ,� Rev. 1-74 <br />