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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx OFFICE USE: 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 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby, made to the San Joaquin Local Health District fora 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 and the+ Rulee and Regulations of the San -Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION t� G��� Y CENSUS. TRACT <br /> Owner's Name Phone <br /> Address City <br /> r <br /> Contractor's Name L7 License # hone , <br /> a . , <br /> TYPE OF WORK (Check): ,fNEW WELL DEEPEN /? RECONDITION /?�DESTRUCTION (7 <br /> PUMP INSALLATION / PUMP REPAIR /7PUMPfREPLACEMENT 17 <br /> ,,A .�+ y . <br /> . Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IT PRIVY , _vy• <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT �-NOTHER ' <br /> PROPERTY LINE*-'6RIVATE DOMESTIC WELL/121- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE -OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria] Cable Tool Dia. of Well Excavation„,_--. -. __1 _.s <br /> �-- -_- <br /> Domestic/private DzfilTed""""R" Dia n T Well Casing <br /> " Domestic/public Driven 'gauge' of Casing <br /> Irrigation Gravel Pack f Depth of Grout Sdjal j <br /> Cathodic Protection Rotary Type -of G- ut �i• <br /> Disposal .... Other Other Information -'` <br /> i Geophysical Surface_Seal_Installed_B -i-�-^ <br /> • Contractor V 5 <br /> PUMP INSTALLATION: <br /> k Type of Pump 4e .'.' H.P. " <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Maierial and Procedure <br /> r <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'constructioti. 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 /> ° PRIOR TO GROUTING AND A.FINAL INSPECTIO <br /> SIGNED E �� <br /> POT ON REVERSE SIDE <br /> FOR ARTMENT USE ONLY <br /> PHASE I 4 <br /> APPLICATION ACCEPTED BY �j�((��� DATE <br /> ADDITIONAL COMMENTS: i. <br /> PI G UTI PECTION PHASE I INAL INSPE 0 <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> -._ 4/75 <br />