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:.. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> jIo <br /> 1601 E_, Hazelton Ave. , Stockton, Calif . <br /> FOR OFFTTE USE: Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> iDate Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> cal Health a permit <br /> ,Application is hereby made torthe San Joaquin Loapplication isDistrict r <br /> made incompliancetwithnSanuJoagt <br /> and/or install the work herein described. This app <br /> County Ordinance No. 1862 and the Rules and Regulations Of the n Joaquin Local Health District <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION 1, 1 <br /> z <br /> Phone <br /> Owner's Name <br /> City III <br /> Address Phon <br /> �Contra�T actoFr's NameY <br /> DEEPEN RECONDITION_/-T DESTRUCTION /_T ` <br /> TYPE OF WORK (Check) : NEW WELL / PUMP REPAIR / / PUMP REPLACEMENT /_T <br /> PUMP INSTALLATION / / <br /> Other <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL"FIELD` L <br /> T y V PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTLIC ION SPECIFICATIONS <br /> IN E ED USE TYPE OF LL <br /> able Tool Dia. of Well Excavation <br /> Industrial Dia. of Well Casing <br /> Domestic/private Drilled <br /> Do stic/public Driven Gauge of Casing Lv <br /> k Gravel Pack Depth of Grout Seal <br /> 9 rrigation Other Type of Grout <br /> Cathodic Protection Rotary Other Information �— <br /> I <br /> Disposal Surface Seal Installed B <br /> t Geophysical <br /> PUMP INSTALLATION: Contractor H.P. ,• <br /> Type of Pump <br /> l _ ~ <br /> �_P.UMP-REPLACEMENT: — / State .Work Done <br /> PUMP 'REPAIR: - / / State `Woik`Done" <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 3 I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distr <br /> and the State of California pertaining to or regulating well <br /> construction. Within FIFTEEN D <br /> work on a new well, I will furnish the San Joaquin Local Health Distr <br /> after completion of my w <br /> WELL DRILLERS REPORT of the well and no them before putting the well in use. The above <br /> information 1 true to the t of my knowledge and be <br /> �I WILL CALL-) FORA GROUT INSPECT <br /> f PRIOR TO GRID NG AN A F I 5P 'CT ON'. �TITr F <br /> i SIGNED PLOT PLAN ON REVERSE SIDE) <br /> (D <br /> I FOR DEPARTMENT USE ONLY ,f <br /> PHASE I DATE J 11 <br /> 1 APPLICATION ACCEPTED BY "( P /X , tj <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> 1 PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE /s2 <br /> �� 1177 . <br />