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SAN JOAQUIN. LOCAL I18ALTH DISTRICT <br /> FOR OFFI E USE: 1601 E. Hazelton Ave., , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - <br /> {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 /> ftCounty Ordinance No. = 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> BADRESS/LOCAT70f <br /> CENSUS -- <br /> -`± S Ti�ACT <br /> Owner's Name ' <br /> Phone <br /> p Address .e.- (1 fps <br /> ca City <br /> Contractor's Name . License # hone <br />[ TYPE OF WORK (Check) : NEW WELL / / DEEPEN <br /> E /_/ RECONDITION /—/ DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> If DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> PROPERTY .LINE - PRIVATE DOMESTIC WELL _PUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> e ^- <br /> Domestic/private" Drilled <br /> Dia. of Well Casing <br /> Domestid/.public Driven Gauge of Casing <br /> _, Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical t Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor �• <br /> Type 6f ,Pump <br /> H.P. lei <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: /X/ State Work Done ; <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 themell and notify them before putting- the- well in use. The above <br /> information is true to the best of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND :A FINAL INSPETI N t <br /> SIGNED � ITLE + <br /> (D 'AW L LAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Y�ECTT��� <br /> DATEADDITIONAL COMMENTSPHASE II GRSPON PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE $P -J3 -,7 <br /> E H 1426 0'/,77 RNs_- <br />