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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> G <br /> F0 OFFIE'135E• 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Y Telephone: (209) 466-6781 �ra <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 0 w <br /> ' <br /> '_ <br /> .'THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `y /40 <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 Joaquink <br /> County Ordinance 'No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> r <br /> Phone <br /> Owner's Nage <br /> `s <br /> City s <br /> Address r <br /> Contractor's Name r <br /> License # <br /> 3/ Phone2��D, ? <br /> , <br /> mss. <br /> TYPE OF WORK (Check) : NEW WELL .I DEEPEN // RECONDITION /�T DESTRUCTION / <br /> PUMPIINSTALLATION / / PUMP.REPAIR / / PUMP REPLACEMENT I`T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY- WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL k"I 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 ��ravel Pack Depth of Grout-Seal <br /> Cathodic Protection —(/ Rotary Type of Grout <br /> `. Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> 1.�'PUMP INSTALLATION,° Contractor - ' H.P. I <br /> Type of Pump ` <br /> PUMP REPLACEMENT: . / State `Work Done t r I <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate DepthE� <br /> Describe Material and Procedure <br /> 4� 1 <br /> t I hereby 'agree to comply <br /> 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 DAYSi <br /> after completion of my work on a new well;I`wi11 furnish the San Joaquin Local Health District a <br /> ` WELL DRILLERS REPORT of the well`and notify them before putting the . 11 in use The above <br /> information `is't ue to the best of -my .knowledge and belief. I WILL C L FOR A T INS ECTION <br /> PRIOR*TO GROUT -N AND A,FINkVASPECTION. TITLE <br /> SIGNEDi. <br /> D W p�; PLAN �ON-RE EASE SIDE <br /> z FOR DEPARTMENT USE'ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INS ECTION P E II2 INAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY <br /> 1 , 3/76 2M <br />