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a - SAN JOAQUIN LOCAL HEALTH DISTRICT _ p.,, � jA0 � <br /> FOFi i0I'FICE USE: 1,601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby'made to the San Joaquin Local Health District for a permit to construct <br /> an JoaquiUl <br /> and/or install the work herein described. hiisap,ulationstofplicaion�he SaneJoaquin Localin complianceHealthwithSDistrict. <br /> County Ordinance No. 1862 and the Rules and g <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Na <br /> City <br /> Address <br /> Contractor's Name <br /> License #�( Phone -� 3 <br /> TYPE OF WORK (Check): NEW WELL`/Zl . DEEPEN /-7 RECONDITION /? DESTRUCTION �T <br /> PUMP INSTALLATION / REPAIR /� PUMP REPLACEMENT / <br /> Other ET: <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI, - <br /> N ----�— PIT PRIVY <br /> SEWAGE DISP .AL FIELD 0! CESSPOOL/SEEPAGE PIT f�_-wx`O'HER <br /> PROPERTY LINE - PRIVA DOMESTIC WELL''" PUBLIC DOMESTIC WELL <br /> E <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation 'I N <br /> k Industrial —Al <br /> � omestic/private Drilled Dia. o£ Well Casing <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Se ' <br /> l Cathodic Protection Mary Type of Grout <br /> Disposal . .. k I Others_ • Other Information L <br /> Geophysical. ~•' - �-�- Surface Seal Instal ed BY: GA.t <br /> PUMP—INSTALLATION Contractor - " <br /> R.P.Type of Pump <br /> t PUMP REPLACEMENT: State-Work D- <br /> one.< <br /> PUMP '.REPAIR: /-7 State Work Done t <br /> ES.TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material-and-Procedure <br /> t F <br /> t n <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in uee.. The above <br /> I <br /> infoion is true to the be f m kn ledge and belief. I"WILL CALL FORA GROUT INSPECTION <br /> PRIOR UTING AND A FINAL INlo <br /> S ' <br /> 1k TITLE Q <br /> SIGNED <br /> P7--LOT PLAN ONREVERSE SIDE <br /> FOR DEPARTMENT USE-ONLY 7� <br /> P DATE 'l / <br /> ;; <br /> APPLICATION ACCEPTED BY w <br /> ADDITIONAL COMMENTS: PHASE FIN INSPECTION <br /> PHASE II GROUT INSPECTION "INSPECTION BY DATE <br /> f INSPECTION BY DATE _. <br /> 1-74 2M <br /> k 4 O II 1 A 04 Lata 1-74 __ <br />