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.ecc (7 n--r Sri-t-� r <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT } r � <br /> M <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton) Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No%7 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> District, for a permit to construct <br /> Application is hereby made tol the San Joaquin Local Health D <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 Reg ations of the San Joaqua.n Local Health District. <br /> r CENSUS TRACT + <br /> JOB ADDRESS/LOCATION <br /> Phone d <br /> Owner's Name a <br /> t � <br /> City <br /> Address <br /> Contractor's Name <br /> License ��d �� Phone <br /> TYPE OF WORK (Check} : NEW WELL DEEPEN `/ I RECONDITION / / DESTRUCTION /-7 <br /> .PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other 1/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 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 /> Domestic/private <br /> Drilled Dia. of Well Casing <br /> Domestic/public s Driven Gauge of Casing l <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of GrOut- <br /> Disposal f Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. . <br /> Type o£ Pump <br /> PUMP REPLACEMENT: I I �State Work .Dane . <br /> PUMP -.REPAIR: / / State Work. Done <br /> DESTRUCTION OF WELL: Well Diameter A proximate Depth _ <br /> -.p .... <br /> ` Describe Material and Procedure <br /> 1 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 notify them before putting- the well in use.. The above <br /> information is true to t�'e est of my knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR T <br /> O TAFIN �JNSP�E�TI N. mITL- <br /> E <br /> SIGNED RL <br /> PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE OF— 3 0 --7 Z— <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: F PRASE III/FINAL INSPECTION <br /> PHASE II GROUT. INSPECTION DATE ' ' V <br /> INSPECTION BY ' DAT INSPECTION BY <br /> 6/77 - 2M <br />