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- --- r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_WZFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> R"FROM DATE ISSUED Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR <br /> (Complete In Triplicate) <br /> Application is hereby mads 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 /> t <br /> .TOB ADDRESS/LOCATION , CENSUS TRACT <br /> Ownerts Name Phone ea" 3 <br /> Address - City . <br /> Contractor's Name _ License Phoneme - <br /> TYPE OF WORK (Check): NEW WELL '.-C DEEPEN/T RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION /7 PUMP REPAIR'/_7 PUMP REPLACEMENT 17 <br /> Other <br /> -DISTANCE TO NEAREST: SEPTIC TANK SEWER• LIIJES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Q ++ 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; 3-M <br /> Domestic/private Drilled Dia.. of Well Casing <br /> Domestic/public Driven Gauge,of. Casing ? - 1 <br /> Irrigation Gravel Pack Depth of Grout Sea SO <br /> Cathodic 'Protection RotaryType=of..Gr-out <br /> Disposal `: "= = -Other ; Other Information ( , <br /> Geophysical r Surface Seal Installed B <br /> PUMP INSTALLATION: y Contractor <br /> Type sof Pump ({{ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /7 State-Work Done <br /> i <br /> IDES.'TRUCTION OF WELL: Well Diameter',. � Approximate Depth �fl <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. 4 Within FIFTEEN DAYS <br /> I after completion of my work on a new well, I ,kill furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of -the well and notify them;.before p' ting.the..well in use... .The above <br /> information is true to the 'best-of my.knowledge and belsief.. I TWILL CALL FOR 'A 'GROUT INSPECTION <br /> PRIOR .TO TING 'AND A f'I S ECT ON. - <br /> SIGNED --:TITLE- <br /> PLOT PLAN ON- REVERSE SIDE <br /> FOR DEPARTMENT USE. ONLY <br /> PHASE I <br /> 1 APPLICATION ACCEPTED BY m rr DATE <br /> ADDITIONAL COMMENTS: "7a <br /> PHASE II :G I CTION PHASE I FINAL INSPECTION <br /> INSPECTION-BY - - - -...---� -- :.INSPECTION $Y DATE t�-�? <br /> R R -1426- 72av_ 1-71L -- <br /> 4/75 <br />