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- 5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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. x/36 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED <br /> Date Issued <br /> Application is hereby made to' the SanJoaquineLo al In Triplicate) <br /> HealthtDistrict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ; c <br /> t <br /> CENSUS TRACT <br /> Owner's Name " f <br /> Phone •� <br /> Address „ .. .+- <br /> City .. iG.•,. �'�. . <br /> Contractor's Namej <br /> License ��, +.+ •! Phone <br /> k <br /> TYPE OF WORK (Check) : NEW WELL KDEEPEN <br /> _/ / RECONDITION /% DESTRUCTION /_7PUMP INSTALLATION � PUMP REPAIR/% PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES y~ PIT <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE ,PIT ^� ,OTHER <br /> PROPERTY LINE W� R' IVATE DOMESTIC WELT, PU LIC4DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION25PECIFICATIONS <br /> Cable Tool Dia. of Well Excavation41t4e,'a <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of CasingT# <br /> Irrigation Gravel Pack" .......-.Depth of Gi.out Seal_ <br /> Cathodic. Protection Rotary Type of Groin <br /> Disposal Other Other Information <br /> Geophysical 'Surface S"eaL. Atistalliid <br /> PUMP INSTALLATION; Contractor „ <br /> Type of ,Pump <br /> •, sa fH:P. <br /> PUMP REPLACEMENT: / /w State Work'Done-' <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and 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 t.be well and notify them before putting the .well in use. The above <br /> Enformation is truethe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTIN I <br /> aIGNED4;� - <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ; <br />'RASE I F R DEPARTMENT USE ONLY <br />,PPLICATION ACCEPTED BY Z,1_ — <br />.DDITIONAL COMMENTS: DATE /-? -g <br /> PHASE II GROUT INSPECTION / <br /> NSPECTION BY PHASE III/FINAL INSPECTION <br />.,� DATE *,. `INSPECTION BY' �. DATE <br /> .t % ti 4 t*` r <br /> E H 142 •. <br /> Rev. 1-74 1 1'T7 �,� <br />