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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FR70rFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,?A�- a3 <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED. Date Issue <br /> (Complete In Triplicate) <br /> Application is hereby made to' the San Joaquin Local Health District, fox ,a, permit to construct <br /> and/or install the work herein described. This application is made in compliance with .San .Toaquis� <br /> County Ordinance No. 1862 and the Rules andRna at no of Che, San, Joaquin Local Health District. <br /> JOB aNgL=LOCATION o �. i� .Ri' .CENSUS TRACT <br /> Owner's Name _ .yl _ ! — Phone <br /> 2 G City.., <br /> Address <br /> F F License Phone � �® <br /> Contractor's Name � <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /-T DESTRUCTION /7 <br /> PUMP INST LATION -� PUMP REPAIR -7 PUMP REPLACEMENT /7 <br /> r <br /> .Other <br /> DISTANCE TO NEAREST: SEPTIC TANK $$ SEWER LINES . PIT PRIVY '"" <br /> SEWAGE DISPOSAL FIELD ~' C SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/_W+.-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 /> } Cathodic Protection Rotary -Type-of-Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION <br /> Contractor <br /> -Type" .of Pump c (® H.P. <br /> PUMP REPLACEMENT: . / / State Work Done - <br /> State <br /> .REPAIR: /� State Work Done <br /> PUMP <br /> _ _ <br /> DESTRUCTION OF WELL: Well, Diameter Approximate Depth �� <br /> Describe Material and Procedure_. <br /> I hereby agree to comply.zwith. all�laws'i,and. regulations of =the -San Joaquin~Local Health District <br /> and the State of California pertaining to or regulating well"'cons truction. .'Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San 'Joaquin Local Health District <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.khowledge and belief. I WILL CALL FOR'A ,GROUT INSPECTION <br /> PRIOR'TO GROUTING 'AND A FIML. S CT N. <br /> SIGNED � �! TITLE <br /> ADRAW LOT PLAN ON REVERSE SIDE <br /> FOR MENT USE ONLY <br /> PHASE I iv/ /j <br /> � e DATE " <br /> APPLICATION' ACCEPTED B <br /> ADDITIONAL COMMENTS: <br /> PHASE G OUT SPECTION <br /> I PHASE F NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY a DATE .s' 7 <br /> ,� u 14?w mer`" 1_76 !IZ75 2m <br />