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_ SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ./-t— S3OP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> `2nd/or install the work herein described his application is made in compliance with San Joaquit <br /> County Ordinance No. 18622 a the Rule d Rpgulatiojis of he San Joaquin Local Health District. <br /> .d OB ADDRESS/LOC42TM ✓ _ �� CENSUS TRACT <br /> )wner's Name( _ ' Phone9 <br /> address <br /> :ontractoz 's Name License/�f�" —' �Phon <br /> 1.� <br /> NPE OF WCRK (Check) : NEW WELI. / / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> `.,)IyTANCE 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 <br /> ` INT_ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> ^_ Industrial Cable Tool Dia. of Well Excavation G <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 Type of Grout <br /> L Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> ?UMP INSTALLATION: Contractor <br /> L Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done \ <br /> � <br /> r <br /> PUMP REPAIR: State Work Dona �""�- _ <br /> �(' L��e <br /> 1 <br /> )F.STRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> b 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 well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 6PRIOR TOG UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE a <br /> (M ,PLOT PLAN ON REVERSE SIDE) r �f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/i DATE <br /> VADDITIONAL COMMENTS: <br /> PHASE II 0 W&ION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY // i� DATE :2- <br /> F <br /> F H 149A Ra,.- 1_74 - 3/76 Z4 <br />