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,r <br /> SAN 30AQUIN LOCAL HEALTH DISTRICT <br /> FOFZFFIC USE: 1,601 E. Hazelton Ave. , Stockton, Calif. <br /> f# Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z Sj6kJ <br /> r 613 'e3 <br />` THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Llis-7s" <br /> (Complete In Triplicate) <br /> I Application is hereby madeqo the San Joaquin Local Health District for a permit to construct <br /> and/ortinstall the work herein described. This application is made in compliance with San Joaquin <br /> J County 'Ordinance No. 1862 an.d he Rules and Reg a, -i-o`ns ofA-*nocal Health District. <br /> �.. <br /> 18 <br /> _ry <br /> t� <br /> JOB ADDRRSS/LOCATION CENSUS TRACT <br /> Owner's Name i " ! Phone <br /> Address City <br /> Contractors Name `; License ; - Phone <br /> TYPE .OF WORK (Check): NEW WELL /6'1 DEEPEN.=-/.? RECONDITION /_7 DESTRUCTION /_7-� PUMP INSTALLATION I PUMP'RE 'AIR / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAKK___ SEWER LINES PIT PRIVY <br /> { <br /> SEWAGE DISPOSAL FIELD______^_. CESSn_OL/..S.EEPAGE_PIT.�:.:.R._ OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS " f <br /> Industrial 4 Cable Tool Dia. of Well Excavation . <br /> Domestic/private Dr3led Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 <br /> . . _Irri.gation I Gravel Pack "� Depth of Grout Seal.' I � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other .Other Information � <br /> Geophysical. ► Surface Seal Installed 'Bi: <br /> PUMP INSTALLATION: Contractor ., . <br /> } Type iof Pump _, fray s R.P. . <br /> PUMP REPLACEN,ENT: '' / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <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/ <br /> WELL DRILLERS REPORT of the well and notify thew 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 /> PRIOR TO GRO TING ANDA INAL JNSPECTION. <br /> r SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY V DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ZXNAL INSPECTION <br /> INSPECTION BY DATE INSPECT10N BY DATE <br /> Y <br /> �H`'ld76 Rev. 1-74 - 4/75 <br />