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SAN JOA UIN LOCAL HEALTH DISTRICT <br /> ISTRICT <br /> FOF,.O FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL 3 .3P <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 6-/ 7b <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 Rule's and Regulations of the San -Joaquin Local .Health District. � <br />. JOB ADDRESS/LOCATION <br /> L4LIat CENSUS TRACT <br /> Owner's Name ad Phone ' <br /> Address l3Ti Al City <br /> Contractor's Name .� License ; Phone [ { <br /> TYPE OF WORK (Check) : NEW WELL -/ 7 DEEPEN/? RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR -_& PUMP REPLACEMENT /? <br /> Other /-7 . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <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 Drilled Dia, of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A H.P. /d <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPAIR: State Work Done �d <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material, and Procedure <br /> r <br /> rI 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 <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe..well. in-:use.... .The above <br /> information is true to the-best-of. myo eoe -belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO G UTING 'AND A FINAL INSPECT N. <br /> SIGNED,,_ , .. ITLE _ <br /> (Wmw PX9T FIXN ON RE RSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �11 :• . �. DATE ' 6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPE ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r 4/75 2M <br />