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1 <br /> ��F06 <br /> �FIC <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT -Permit- No. 7 7 Ia <br /> THIS PERMIT EXPIRES 1 YEAR` FROM DATE ISSUED Date Issued /- <br /> t (Complete In Triplicate) <br /> 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 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' CENSUS TRACT ' <br /> Owner's Name , tA Phone ; <br /> Address j) _. City <br /> Contractor's Name ' ..- � License # &4 C ( <br /> ,TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION Xl PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 /> —, f!!� Domestic/priva.te Drilled Dia, of Well Casing v , <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout„Seal d v <br /> `Cathodic Protection_ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface_Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of EPump H.P. r. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP � /�'/ State Work Done �� 600 <br /> 107 "too IV P <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 the well and notify them before putting thewell in use.. . The above <br /> information is true to the be o y k D'r` edge d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A <br /> SIGNE TITLE �' <br /> (DRAW PLOT PLM0 VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I PECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ��� DATE l0` 7� <br /> F <br /> F H 1426 2M <br />