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to. tC <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTFOR.gOFFIUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date- Issued ,. <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 and1the Rules and Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION / C/ CENSUS TRACT � <br /> Owner's Name <br /> Phone , ' <br /> Address City ' _ <br /> Contractor's Name , y License #/ ;. ''PhQtte <br /> TYPE OF WORK (Check): NEW WELL l=T DEEPENI-7/-' RECONDITION /_7 DESTRUCTION 17 <br /> PUMP INSTALLATION / / PUMP REPAIR -/ PUMP REPLACEMENT / f <br /> �-- - Other /JC/ "e.r ' C _ <br /> DISTANCE TO NEAREST: SEPTIC TANK �S` R LIN rr `� '�" <br /> PIT PRIVY <br /> . SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER j <br /> PROPERTY LINE PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF_WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial f Cable Tool Dia. of Well Excavation <br /> Domestic/private I 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 /> Disposal' Other Other Information <br /> Geophysical ; <br /> Surface Seal Installed S <br /> PUMP INSTALLATION: Contractor � g> � <br /> Type,.of}Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: <br /> State York Done . <br /> 7/,;o7/,;o ,na <br />)ESTRUCTION OF WELL: Well Diameter <br /> Depth- <br /> Describe <br /> `� APPxoxiinate " <br /> Describe Material and Procedure <br /> E hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind the State of California pertaining to or regulating well "construction. Within. FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District, a <br /> JELL DRILLERS REPORT of the well and notify them before putting. the..well. in.use.... .The above <br /> Lnformation is true to the_best .of my..knowled e d bel-'e= I WILL CALL 'FOR 'A GROUT INSPECTION . <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> UGNED � <br /> DRAW P LAN ON REVERS SIDE <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br />,PPLICATION ACCEPTED B V <br /> j. DATE <br /> ADDITIONAL COMMENTS: ns <br /> ,ev-e / <br /> PHASE IIGROUT NSPECTION ^rr��. .S�r �, S�� PHASE III FINAL INS CTI(3N <br /> INSPECTION BY DATE INSPECTION BY U DATE22Sr <br /> E H 1 26 Reiv. 1-74 <br />