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SAN JOAQUIN LOCAL, HEALTH DISTRICT er <br /> OF]nICE USE• 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone: (209) 466-6781 7f-.;3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE NE Na. — <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the cribed. Thisoappl.in Joaquin Lcal lealth cationDistrict made inra permit compliancetwithconstruct <br /> uSanJoaquin <br /> and/or install. the work herein desc <br /> . s and Regulations of the San Joaquin Local Health District- <br /> county Ordinance. No, 1862 and the Rule <br /> {' CENSUS TRACT <br />{, JOB ADDRESS/L� ® �" 4 �------- <br /> Phone <br /> Owner's Name <br /> City <br /> AddressE� <br /> Contractor s Name '40 5 <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPE / / RECONDITION_/ / DESTRUCTION /_ <br /> PUMP INSTALLATION / ;/ PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 4-- SEWER LINES�_t—PIT PRIVY <br /> K <br /> SEWAGE DISPOSAL AFIELD r"� CESSPOOL/SEEPAGE PIT / $--OTHERrPUBLIC <br /> WE <br /> PROPERTY ZINE RIVATE DOMESTIC WEf LC TRUCTION DECIFICATIONS C~ <br /> INTENDED USE TYPE OF WELLOMESTIC <br /> f <br /> Industrial Cable Tool Dia. of Well Excavation <br /> '( <br /> Drilled Dia. of Well Casing <br /> Domestic/private <br /> —��- � Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation �Gravel� Pack Depth of Grout Seal <br /> Type of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other �_ <br /> �- Suxface� Seal Insta <br /> Geophysics] <br /> PUMP INSTALLATION: Contractor AVH.P. _ <br /> Type of Pump - � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> to Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Matezial 'and Proced e <br /> f the San oaquin Local Health District <br /> I herebyagree to comply with all laws and regulations oJ ° <br /> and the State of California pertaining to or regulating well construction. WithHealthTDDistrict <br /> after completion of my work on a new well, I will furnish the San Joa The above <br /> WELL DRILLERS REPORT of the well and notify them before putting.t w n s GROUT INSPECTION <br /> information is true to the best of my knowledge ,and belief. _ I CA 0, � <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED <br /> W PL T PL ON R FRSE S <br /> FOR DEP TMEN USE 0 LY <br /> PHASE I M DATE I5 <br /> APPLICATION ACCEPTED BY <br /> -------------- <br /> ADDITIONAL COMMENTS-, p gE /FINAL, INSPECTION <br /> PHASE II GROUT INSPECTION I TION BY DATE <br /> INSPECTION BY i DATE <br />