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r� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601, E. Hazelton Ave. , Stockton, Calif. <br /> . <br /> FaF�,:OFicE USE: <br /> j <br /> Telephone: (209) 466-6781 Permit No. u <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> [ Date Issued. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A ' _ / <br /> t (Complete In Triplicate) <br /> Application 'is herebynmade to the San Joaquin Local Health <br /> District de inrco pliancea permit twithnSanuJoaquin , <br /> PP <br /> and./or install the work herein described. This app r <br /> County Ordinance'No. 1862 and the Rules and Regulations of the San. Joaquin Local Health District. f <br /> r" <br /> CENSUS TRACT <br />;-JOB .ADDRESS/LOCATION <br /> Phone <br /> Owner's Name <br /> city <br /> ''..-Address 12 <br /> , .License # Phone <br /> Contractor's Name . i <br /> r <br /> • J � <br /> x;t _ <br />..,.TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION p <br /> DESTRUCTION <br />' PUMP INSTALLATION PUMP REPAIR <br /> O therR l/ <br /> SEWER LINES PIT PRIVY <br /> '. DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER �_ q <br /> t• SEWAGE'DISP0 AIA, —,IELD <br /> .. PUBLIC DOMESTIC WELL <br /> i PROPERTY LINE -- PRIVATE DOMESTIC WELLCON TRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> '<. , ` Cable Tool Dia. of Well Excavation <br /> Industrial , } Dia. of Well Casing � <br /> Domestic/private Drilled f Gauge of Casing <br /> It Domestic/public ; (Driven $ <br /> Irrigation I Gravel Pack.' Depth of Grout Seal <br /> Cathodic Protection f Rotary , of Grout <br /> Type) .-_-�..-_.---•--� --�- <br /> Disposal I. Other€—Other, <br /> r <br /> ,Su-dace Seal -Installed <br /> Geophysical _ <br /> .PUMP INSTALLATION: Contractor„ H;P. <br /> ,- Type of Pump <br /> 'r: PUMP REPLACEMENT• / / State Work Done <br /> PUMP .REPAIR: / State Work Done R . <br /> Approximate Depth <br /> ' DES-TRUCTION OF WELL: Well. Diameter <br /> 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-re gulating well"construction. Within FIFTEEN DA S <br /> after completion of my work on anew well, I. wiTl furnish the San Joaquin Local Health District a <br /> SWELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the �best of m . I WILL CALL FOR A GROUT INSPECTION <br /> Ly knowledge and belief <br /> PRIOR TOG UTING AND A INAL S TION. 1 ,y `TITLE 16, <br /> --- <br /> ' SIGNED (DRAW PLOT PLAN,OTkREVERSE SIDE) <br /> E•: <br /> FOR D P-ARTMENTUSE *ONLY <br /> PHASE I DATE <br /> "`APPLICATION ACCEPTED BY <br /> ":.ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II. ROUT NSPECTION INSPECTION BY DATE ,7 7� -/,'I` � <br /> IN BY DATE <br /> 1/77 . _ 2M <br /> 4 in 1_7A ... -.. <br />