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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0TZFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PU11P PERMIT Permit No. <br /> F THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> F (Complete In Triplicate) <br /> I Application is hereby made to the San Joaquin Local Health District for a.permit' to construct <br /> and/or install the work herein described. This application is made, in 'c'om'pliance with San-Joaquin <br /> i County Ordinance No. 1862 and the Rules and Regulations of the1an -J6a4d'in;Local Health 'District. <br /> JOB ADDRESS/LOCATION. <br /> �XacCENSUS :TRACT <br /> Owners Name , Phone <br /> Address City [ <br /> 1.. <br /> Contractor's Name S a' License ` / 3 7 Phoria 6 heW <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/-7 RECONDITION /-7 DESTRUCTION 'f7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR-/-7 PUMP REPLACEMENT /Z <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I` SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY .LINE - PRIVATE DOMESTIC WELL-' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .Cable Tool Dia.. of Well Excavation <br />„ Domestic/private Drilled Dia, of Well Casing <br /> _Domestic/public - -Driven ==� . `_ : Gauge of�`Casirig .. ,` <br /> Irrigation Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout q <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B : ' v <br /> CD <br /> PUMP INSTALLATION:, Contractor <br /> Type .of Pump ('-J . (.r o, H.P. " � <br /> PUMP REPLACEMENT Ll State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br />' DESTRUCTION OF WELL Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agreeto -comply -with-all Laws and regulations of-the San Joaquin Local Health Districts <br /> f-hrid-the State'of Cali'fo`rnia pertaining to or regulating well '-construction.. Within FIFTEEN DAYS` <br /> f after completion of my work`oa a new well, I will furnish the San'Joaquin Local, Health District <br /> WELL DRILLERS `REPORT of"the well and notify them before putting the-well. 1n:use.... The above <br /> information is true to the-best of- my. owledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> I� PRIOR TO GROUT G 'AND A FINAL INSPECTI <br /> •SIGNED _ �_.' TITLE <br /> D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .. ,. _._...., " <br /> APPLICATION" ACCEPTED DATE z . <br /> ADDITIONAL COMMENTS: "T <br /> PHASE II PHASE I I FINAL INSPECTI N / <br />` INSPECTION BY , .,� - DATE INSPECTION BY DATE <br />*_ E H 1426 Rev.. . L/7 q 2M1-74 .. � _ _. <br />