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SAN JOAQUIN LQCAL� HEALTH DISTRICT <br /> FOE OFFICE USE: 1.601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued !�/ <br /> Application i (Complete In Triplicate) <br /> s hereby made to the San Joaquin Local Health District <br /> a permit <br /> and/or install the work herein described. This application is made inrcompli ncetwithnct SanuJopquin <br /> County Ordinance No. 1862 and the Rules a d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , <br /> I <br /> CENSUS TRACT <br /> Owner's Name <br />'4 Phone ' <br /> Address <br /> Contractor's Name <br /> y r <br /> License-13e- <br /> ' i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN _~ <br /> _/ / RECONDITION /_/ DESTRUCTION / 7 <br /> PUMP INS ALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> # Other <br /> DISTANCE TO NEAREST,: SEPTIC TANK <br /> SEWER LINES IT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> InduCONSTRUCTION SPECIFICATIONS <br /> strial / Cable Tool Dia, of Well Excavation Er / U <br /> L�Domest'lc/private Drilled Dia, of Well Casing � <br /> Domestic/pub4ic Driven Gauge of Casing <br /> Irrigation 0 Gravel Pack Depth of Grout Seal <br /> Cathodic{ ProtType of Grout <br /> Disposalf 'ection Rotary Other Other Information, "— <br /> Geophysca_l I <br /> Surface Seal InstalledBye` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. .' <br /> PUMP REPLACEMENT; /—/�"State,.Work Done a � <br /> PUMP °,REPAIR: �.`b'..' <br /> / /State Work Done <br />)E&TRUCTION OF_.WELL; �4" V ` <br /> # Well; Diameter. . . . !t Approximate Depth - <br /> Describe Material and Procedure <br /> t hereby� Wo4ompOyWLW--a ll laws and regu at.ions-'o �te an Joaquin'oocal"Heal District <br /> and the State,-of-Californialper�tairiing to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wd11, I will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of the well and notify them before putting= the. well in�use..­ The'above <br /> Lnformation__is_true_t .. he bestloftmy knowledge and belief. I WILL CALL FOR A GRQUT INSPECTION <br />`RIOR TO,, G U TNG AN A INAL 'CT ION, <br /> iIGNED � � TITLE <br /> (DRAW PLAT PLAN ON REVERSE SIDE) <br />'HAS E T <br /> FOR DEPARTMENT USE ONLY, <br /> APPLICATION ACCEPTED BY DATE/e <br />,DDITIONAL COMMENTS: <br /> I-)"PHAS I GROUT INSPECTION WIZIIFI4N �D�AT <br /> NSPECTIONNSPECTION BY DATE p J INSPECTION B <br /> E H 76?F, 770.. 1_ -7 1. <br />