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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y <br /> OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif- <br /> Telephone: <br /> alif.Telephone: (209) 466--6781 Permit No• �p�l� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT L�------ <br /> wDate Issued -3- <br /> THIS PERMIT EXPIRES 1,YEAR FROM.DATE ISSUED <br /> (Complete In.Triplicate), <br /> a permit o. constrct <br /> Application is hereby shade to the San Joaquin Loallilcationealth �istmade inrcompliancefiwith .SanuJoaquin, <br /> and/or install the work herein described. f app. uin,Local Health District. <br /> County Ordinance No. 1862 and the Rules and Regulations o.f .the San Joaq. .I <br /> CENSUS TRACT.-_� <br /> JOB ADDRESS/LOCATION Q � - <br /> Phone <br /> Owner's Name <br /> p City <br /> -------------- <br /> Address O �� <br /> License <br /> Y/ Phon � <br /> R Contractor's Name <br /> TYPE OF WORK (CheckEMENT <br /> PUMP_) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION / - <br /> INSTALLATION / PUMP REPAIR / / PUMP REPLAC <br /> _ . <br /> p Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKS 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 4F WELL CONSTRUCTION SPECIFICATIONS ! <br /> Industrial Cable Tool Dia. of .Well Excavation �,.._�._.-- <br /> Domestic/private Drilled Dia, of Well Casing <br /> ----� <br /> Domestic/public ublic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout• Seal <br /> Type of Grout <br /> Cathodic Protection •Rotary <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> f e <br /> k PUMP INSTALLATION: Contractor _ H.P. <br /> Type of Pump - <br /> -------------- <br /> s <br /> h PUMP REPLACEMENT: / / State Work Done <br /> f <br /> PUMP .REPAIR: State Work Done <br /> t / / <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> l Describe Material. and Procedure <br /> E I hereby agree to comply with all laws and regulations of the <br /> ecSan Jo ction .in LoWithcal Health District <br /> ` and the State of California pertaining to or regulating <br /> after completion of my work on a new well, I wEEN DAYS <br /> ill 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 /> I WILL CALL FOR ,A GROUT INSPECTION <br /> ' information is true to the best of my knowledge and belief. <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED �F <br /> 9213 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY / <br /> I PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS III/ INAL INSPECTION <br /> PHASE I GROUT IN ECTION INSPECTION BY DATE z� <br /> INSPECTION BY DATE <br /> (i3b/77 21i <br /> R, H 1426 Rev. 1-74 _ -- <br />