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SAN JOAQUIN LOCAL HEALTH DISTRICT 12. t <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 -7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District' f6r a permit to construct <br /> and/or install the work herein described.0 This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. f <br /> JOB ADDRESS/LOCATION CENSUS TRACT - <br /> Owner's Name Phone, 5_,`���ar <br /> -PAR <br /> Address City <br /> Contractor'.s Name � � �� � �° License #34P y y Phone 3 --- <br /> TYPE OF WORK (Check) : . -NEW WELL DEEP N ' /- RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ` SE14ER LINES PIT PRIVY <br /> ,Y -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS a� OTHER <br /> 4�---- — PROPERTY -1YINE - PRIVATE DOMESTIC WELL PUBLIC _DOMESTIC WELL _ <br /> INTENDED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS - � <br /> Industrial _�-,.Cable-Tool :pia. of Well Excavation <br /> Aomestic/primate -'' Drilled --:-.Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> --- lrrigation Gravel Pack Depth of Grout Seal <br /> _=Cathodic Protection Rotary Type of Grout -A5/"- 9. _ <br /> ..Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP `INSTALLATION: " Conntract r, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:'""`"""' / / State Work Done <br /> DES-TRUCTION OF WELL: Well 3-ameter 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 well •construction. Within FIFTEEN DAYS <br /> after':.completion of. my_work-on. a .new well, I will furnish the.-San--Joaquin-Loc-a-l-Health• Bi-strict a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL, CALL FOR A GROUT INSPECTION <br />,PRIORITO GROUTING AND A INAL INSPECTION. <br /> SIGNER TITLE T.1 A&�Ili52 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) T— <br /> FOR DEPARTMENT' USE ONLY <br /> PHASE; I <br /> APPLICATION ACCEPTED BY DATE �O <br /> ADDITIONAL COMMENTS: <br /> PHASE I INSPECTION PHASE' III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 6/77 _ 2M <br />