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I/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �FQF OFFICE USE: ; / }1601 E. Hazelton Ave. , Stockton, Calif. <br /> VV . Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -/SSD <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED Date Issued z �$" <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 Joaquir <br /> County Ordinance No. 1862 �d the Rules and Regulations of San Joa La a1 Health District. <br /> ZG Azar <br /> JOB ADDRESS/LOCATION CENSUS TRACT __-- <br /> Owner's Name T Phone <br /> ' k <br /> k <br /> M Address City <br /> Contractor's Name / License AA d1W Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 _ V <br /> PUMP IINSTALLATION 4"/ 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 /> Domestic/private - - Drilled .Dia. of Well Casing <br /> Domestic./public _ 'Driven. _ --Gauge of Casing <br /> Irrigation _ Gravel Pack . Depth of Grout Seal <br /> F Cathodic Protection Rotary .Type of Grout <br /> _Disposal Other Other Information _ <br /> k Geophysical. -Surface Seal Installed B : <br /> E <br /> PUMP INSTALLATION: Contractor Z <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / iiia State Work Done <br /> PUMP :REPAIR: / / State Work Done <br /> DESTRUCTION 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 we11"construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District s <br /> WELL DRILLERS REPORT of thelwell and notify them before putting the. well in use.. The above <br /> information is true the :best of my knowledge and. belief. I' WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AN AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW ;PLOT PLAN ON REVERSE SIDE) <br /> #OR .DEPARTMENT USE ONLY <br /> PHASE I / 'p <br /> APPLICATION ACCEPTED BY , DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT I PECTION PHASE III/FI INSPECTIONq <br /> INSPECTION BY DATE INSPECTION BY DATE U- / r <br />