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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THISPERMIT EXPIRES I 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 and the Rules and Regul 'ons of the San Joaquin Local Health District. <br /> JOB: ADDRESS/LOCATION CENSUS TRACT i <br /> I <br /> T Phoned <br /> Owner s Name <br /> � <br /> Address city' <br /> Contractor s Name .� <br /> LicenseFd �� Phone �. <br /> ,9_ ekzi�iz� xi <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/_/ RECONDITION / / DESTRUCTION /7 Q li <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other /+.J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY' ! <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �11 <br /> PROPERTYILINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q� <br /> Industrial I Cable Tool. Dia. of Well Excavation 'DF <br /> Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> I-r-riga-tion---- Gravel.—Pack- --.Depth•-ofKK-Grou-t Sea-1 <br /> Cathodic Protection` 1 Rot ar Type of Grout �V <br /> Disposal , r. Other Other Information +, <br /> Geophysical Surface Seal Installed B : 1 <br /> PUMP INSTALLATION: Contractor E <br /> Type''6f Pump ' H.P. E <br /> a <br /> PUMP REPLACEMENT: 'State Work Done <br /> � I <br /> PUMP '.REPAIR: /"'7""-State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: We-i�iameter PP p <br /> Describe Material and Procedure <br /> y <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 -a <br /> WELL DRILLERS REPORT of the well and no 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 TOG UTING FINAL INSPECTION. <br />'SIGNED TITLErM-?-� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F. FOR DEPARTMENT USE ONLY <br />.APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS CTION PHASE IJIVIN INSPECTION <br /> ,INSPECTION BY DATE INSPECTION BY DATE 2 � � <br /> F H 7'126 RPv. 1-74 r� __ - - <br />