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SAr'`10AQUIN LOCAL HEALTH DISTRICT <br /> ,OF- OFFICE USE: <br /> 1601 i. ,Hazelton Ave. , Stockton, Calif <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> /THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J <br /> (Complete In Triplicate) <br /> ct <br /> ?plication is hereby made to the San Joaquin Local Health District for a permit to constxuJo <br /> ad/or install the wank herein described. is <br /> SaneJoaquincompliance <br /> HealthSan <br /> District�n <br /> aunty Ordinance No. 1862 and the g <br /> OB ADDRESS/LOCATION <br /> 9 CENSUS TRACT <br /> M Phone 36 G 0� 0 <br /> wner's Name <br /> ddress � 7 City <br /> p <br /> ontractor's Name <br /> License ��� Z Phone36. <br /> 'YPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION FT <br /> PUMP INSTALLATION/ / PUMP REPAIR . PUMP REPLACEMENT I;T <br /> Other / / <br /> AST NCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> �i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pro Rotary Type of Grout <br /> Disposal Other , Other Information <br /> Geophysical Surface Seal Installed By: <br /> �,a � r <br /> PUMP' INSTALLATION: Contractor t <br /> H.P. <br /> Type of Pump <br /> . i <br /> PUMP. REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done 1 ! , <br /> l <br /> f Approximate Depth _ <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> DAYS <br /> and`�the State of California pertaining to or regulating well'constroaquin. Within FIFTEEN riot <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is ue to. the- st of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G DSA AL INSP ION. TITLE _ <br /> ! SIGNED <br /> DRAW P1OT PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT. USE ONLY <br /> PHASE I DATE 3 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: i. PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE r' <br /> INSPECTION BY I DATE <br /> 3/76 2M <br /> - -- - . _ <br /> 1 , <br />