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. f r <br /> ' MA ✓Y�'"� SAN JOAQUIN LOCAs, HEALTH DISTRICT` r <br /> �� n' 6 <br /> FRO- OFFICE USE: fY/ 1601 E. Hazelton. Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> r� (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 hereia described: This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, ' <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> .Owner s Name Z. Phone ' <br /> Address 6 0 CityI� <br /> Contractor's Name <br /> License # hone 7 7-g <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN -/7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP jNSTALLATION /_/ PUMP REPAIR'' PUMP REPLACEMENT //7 <br /> Other'!/ / <br /> 'i <br /> DISTANCE TO NEAREST: SEPTICATANK SEWER LINES PIT PRIVY <br /> SEWAGE ,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOBESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation �J <br /> Domestic/private !i Drilled Dia. of Well Casing <br /> Domestic/public A Driven Gauge of Casing <br /> Irrigation t Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection :i Rotary Type of Grout <br /> Disposal V ii Other Other Information " <br /> Geophysical ff Surface Seal. Installed BY: _ <br /> s „ <br /> j PUMP INSTALLATION: Contractor, <br /> f Type `of Pump H.P. ' <br /> i PUMP REPLACEMENT. /` / 'State Work Done <br /> PUMP 'REFAIR: / _�.Sta.te-_Work- Donees ^ - - <br /> DESiTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t 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'worklon a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the lwell and notify them bef.ox putting the-well- in in use.... The above <br /> information is true to the.best-of my..krib`wle n be f. I WILL CALL FOR A GROUT INSPECTION <br /> ` PRIOR TO GRO TING AND A FINAL INSPECTION. <br /> SIGNED <br /> ON REVER SIDE) <br /> I FA DEPARTMENT USE ONLY <br /> PHASE-I <br /> APPLICATION ACCEPTED BY DATE. <br /> ADDITIONAL COMMENTS: = <br /> PHASE II GROUT NSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE " -INSPECTION BY DATE <br /> ~--; <br /> F. R 167F,... Raw- 1_71A 1^ 2M <br />