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SANSJOA(r&L HEALTH DISTRICT <br /> k FOA °OFFICE USE: Ol �. Hazelton ,ve. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2s12-Z <br /> p�c? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> C (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 aria the Rules and gulations of the San Joaquin Local Health District. <br /> t <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> owner's Name Phone <br /> Address 1 <br /> � city <br /> License " Phone <br /> Contractor's Name j <br /> lel C' <br /> YTYPE~OF WORK (Check): NEW WELL L-7 DEEPEN/7 RECONDITION /_T DESTRUCTION <br /> PUMP,,INSTALLATION / / PUMP REPAIR /=/ PUMP REPLACEMENT I�T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SE AGEDISPOSAL 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 /> '�K. Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing_ <br /> r°rigation --7t —=Gravel-Pack Grout Sea`1`_�_-`. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ,j. Other Other Information <br /> . .Geophysical ' » Surface Seal Installed By: +` <br /> .: <br /> PUMP/INSTALLATION: Contractor / ` <br /> Type of:Pump H.P. <br /> 7. <br /> PUMP,REPLACEMENT: . State- Work Done <br /> PUMPREPAIR: /� ,„State Work Done _ <br /> DESTRUCTION 'OF WELL: Well Diameter �, Approximate Depth <br /> Describe Material and Procedure <br /> Ihereby agree to comply with all laws and regulations of .the San Joaquin Local Health 81at:s3:ct <br /> ` aTad the State of Galifoxnie�pertaining to or .regulating well construction. Within FIFTB�i DA <br /> after`campleticin of my wark'. on a-new well, I will furnish the San Joaquin Local Health, Dlstric.t a <br /> k ;LLL DRILLTRS RaORT_of_.the._well and notify=them before-_-put:t:ing-the .well in use: The abope' ;w <br /> informgtion li_EruW to the best of my knowledge and belief. I WILL CALL FOR A GROUT NSPECTi <br /> # PRIOR TO GROUWkG AND A FINAL NSPECT N. '* <br /> f SIGNED TITLE ` <br /> D W.: : PLAN ON ME SIDE <br /> FOR'DEPARTMENT USE ONLY <br /> PHASE I <br /> ` APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PUS II GROUT INSPECTION PHA III �- AL INSPECT .N` <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 7b 2!4< <br /> E H 1426 Rev. 1-74 _ <br />