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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 6,14 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> %, Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 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 /> an /or install the work herein described. This application is made in compliance with San Joaquin <br /> C my Ordinance No. 1862 and 'the Rules and e ulavkjt of t San Joaquin Loea1 Health District. <br /> JOB ADDRESS LOCATy IOCENSUS TRACT <br /> Phone <br /> Owner's Name <br /> , <br /> Address City <br /> Contractor s Name E <br /> Licen/e<'t3��� PhoWe� "t3V7 <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <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 -Z.-s <br /> �BoTiiestic/private Drilled Dia. of Well Casing <br /> Domestic/public.. Driven Gauge of Casing 1-2- <br /> Depth <br /> '� <br />{ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection <br /> Z__-Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical. � Surface Seal Installed B <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 44 P H.P. <br />' PUMP REPLACEMENT: / / State Work Done <br /> --State -Work-Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j <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 /> lafter 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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TILE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 0-11 <br /> DATE <br /> 1ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GRDUT INSPECTION DATE <br /> INSPECTION BY., DATE INSPECTION BY Vii!/. _ <br /> 1 1 77 : 2M <br /> k F <br /> 9 lL9A Riau. 1-74 <br />