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SAN JOAQUIN LOCAL HEALTH DISTRICT H <br /> FOR,O PICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209),.466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT- EXPIRES 1 YEAR PROM DATE ISSUED Date Issued .2 <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 Joaquin: <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sac: Joaquin Local Health District, <br /> 309 ADDRESS ILOCATION . '✓ (a an TF . r <br /> CENSUS TRACT <br /> or <br /> Owner's Name Phone <br /> Address7r a <br /> A City <br /> Contractor's Name License Phone y � <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN -/7 RECONDITION F7 DESTRUCTION /-j <br /> PUMP INSTALLATIONPUMP'REPAIR / / PUMP REPLACEMENT <br /> Other /J -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (. <br /> PROPERTY LINE - PRIVATE DOMESTIC -WELL PUBLIC DOMESTIC WELL V <br /> INTENDED USE TYPE OF WELL <br /> 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 Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection. Rotary 'hype of Grout <br /> Disposal Other Other Information <br /> Geophysical Surf <br /> ace Seal Installed By, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump c� rr t� H.P. <br /> PUMP REPLACEMENT: ., / / State Work Done <br /> PUMP )C/ _ State Work, Done .1rriD4�r/, f 0. <br /> DES-TRUCTION OF WELL: Well Diameter 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 Local Health District a � <br /> WELL DRILLERS REPORT of the well and notify them before putting.. the..wel.l. in.use.... The above <br /> information is true to the,best of my. knww ed a and belief. I. WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL • ECTTOW. <br /> SIGNED _ TITLE Rr,� <br /> (DRAW PLOT PLAN ON FRSE SIDE <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE I OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY Zff <br /> 1ZDATE INSPECTION BY DATE <br /> E H 1426 Rp-a- 7.x76 <br />