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�VSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton., Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRU.CTION'OR PUMP PERMIT Permit No. �� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 � <br /> (Complete In Triplicate) <br /> Application is hereby ?lade to the San Joaquin Local, health District fora permit to construct <br /> and/or install the work herein described. This app4cation 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 ADDRESSA J <br /> CENSUS TRACT 1. <br /> f : <br /> Owner's Name <br /> Phone <br /> Address <br /> City " <br /> f Contractor's Nana • / License <br /> Phone <br /> r� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN_, RECAIdDITION�/? DESTRUCTION f7 <br /> PUMP INST TION- ? PUMP REPAIR /-7PUMP REPLACEMENT /? <br /> Other /% �T"' <br /> DISTANCE TO NEAREST: SEPTIC TAN -SEWER LINE 1 PIT PRIVY <br /> SEWAGE DISPOSALrFIELD --� CESSPOOL/SEEPAGE PIT ---- OTHER <br /> P1tOPERTY LINPRIVATE DOMESTIC WELL _ fpUBLIC DOMESTIC WELL` <br /> INTENDED USE TYPE OF WELL ,U1 <br /> Industrial CONSTRUCTION SPECIFICATIONS _ <br /> Cable Tool Dia."of WellExcavation <br /> �i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/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 Surface Seal Installed BY: b <br /> PUMP INSTALLATION; Contractor <br /> Type. of Pump E } H.P. <br /> PUMP REPLACEMENT: , <br /> / / State Work Done i <br /> PUMP �REPAIR: � - <br /> /,J State Work Done <br /> DESTRUCTION OF WELL; Well. Diameters F <br /> Describe Material and Procedure Approximate Depth7. <br /> 4 ; _ <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.Yto or regal_ a ing te-ZI cPns truc.tion..Within-_FIFTEEN DAYS <br /> after completion of my workona new well,I will furnish the San, Joaquin Local Health District a s <br /> WELL DRILLERS REPORT of the well and notify them before ,putting.. the...well. in.use..,. The above <br /> information is true to the-best-of- my-knowledge- a'n'. d belief:-"'I-WILL CALL FOR_A._GRQUT.INSPECTION <br /> PRIOR TO GROUTING 'AND A -FINAL-INSPECTION' `-- _- - - * -- - <br /> RAW' OT PM ON REVERSE SIDE <br /> FOR D ARTMENT USE ONLY <br /> PHASE I <br />�PLICATION' ACCEPTED BY DATE ' -� <br /> ADDITIONAL COMMENTS: " <br /> P I G UT INSPECTION PHA5 III F NAL INSPECT <br /> INSPECTION BY DATE Z' INSPECTION BY DATE <br /> �E <br /> E H -14. .2.6'-- ltev. 1-74 ' /mac ��,. 6�--5 <br />