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�! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued fid <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made to the San Joaquin Local <br /> applicationDistrict <br /> made infor <br /> com compliance with San Joaquin <br /> and/or install the work herein described. This app <br /> P <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaqui� 1 Health District. <br /> (Aim( <br /> CEN US TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name <br /> City <br /> Address IP <br /> Q License ' Phone <br /> Contractor's Name <br /> DESTRUCTION /�T <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPE / PUMP CONAIRI�N/�P PLACE T <br /> PUMP INST ON / <br /> Other / <br /> SEWER LINES _ PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of TellExcavation <br /> Drilled Dia. of Well Casing \. <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public <br /> _f�Irrigation Gravel Pack Depth of Grout Seal <br /> Type of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other <br /> Geophysical � Surface Seal Installed B <br /> PUMP INSTALLATION: Contractol '-'' ' `••. H P <br /> Type of Pump <br /> PUMP REPLACEMENT: / / , State Work Done <br /> PUMP .REPAIR: <br /> /% State Work Done <br /> _ <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well eter <br /> Describe Material and Procedure <br /> cal <br /> rict <br /> I hereby agree to comply with all laws and regululatin owelleconstruction.an Joaquin LoWithiat <br /> ationnFIFTEENDAYS <br /> and the State of California pertaining to or r g g <br /> after completion of my work on a new well, I will bfurnish <br /> efore put e Sang�theJ Loca above a <br /> WELL DRILLERS REPORT of the well and notify the <br /> information is true the best of my knowledge and belief. I CALL FOR A GROUT INSPEC <br /> PRIOR TO G OUTING FINAL INSPE ION. TITLE <br /> SIGNED DgAW ph T PLAN ON RE FRSE SIDE) <br /> F R DEPARTMENT USE ONLY � LZ�7 4 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE II FIN INSPECTION <br /> PHASE I GROUT INSPECTION INSPECTION BY DATE -Z <br /> INSPECTION BY DATE <br /> 3/76 214 <br /> F H 1426 Rev. 1-74 <br />