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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,ZP- <br /> C THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is hereby m (Complete In .Triplicate) <br /> ade t -the San Joaquin Local Health District for aper <br /> mit <br /> and/or. install the- work herein described. This application is made in compliance with San. Joauin <br /> to construct <br /> County Ordinance No. -1862 and thei,Rules. and-Regulations of. the San Joaquin Local Health District. <br /> 3.Ke E, .y <br /> JOB ADDRESS/LOCATION <br /> 3 yw <br /> Owner's Name CENSUS TRACT l0/-D 2/-(o3 <br /> R <br /> � <br /> Phone <br /> Address .l � <br /> i i .�.���` city , /� . <br />( Contractor's Name ' <br /> 1 License 'Phone <br /> i <br /> TYPE OF WORK (Check) : NEW- WELL / / DEEPENRECONDITION_ // / DESTRUCTION /�� <br /> : <br /> PUMP her / /' PUMP REPAIR / PUMP REPLACEMENT /_ W d <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY _ <br /> t.SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE , TYPE OF WELL <br /> IndustriaCONSTRUCTION SPECIFICATIONS <br /> ] i Cable Tool. Dia. of Well Excavation <br /> _.Domestic/private ! Drilled Dia, of Well Casing <br /> Domestic/public ;, Driven Gauge of Casing <br /> Irrigation i 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:• Contrac,tor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / Std to Work Done <br /> DESTRUCTION OF WELL: Well Dimeter <br /> Describe Material and Procedure Approximate Depth <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 FIFTEENDAYS <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 the best of my knowledge and belief. .,I WILL CALL FOR A GROUT INSPE <br />'RIOR TO GR NG AND A . A INSPEC 'ION. CTION <br /> SIGNED �.� <br /> TITLE <br /> I (DRAW PLO - PLANON EVERSE STD <br /> FO ARTME <br />?HASE I i, NT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: L DATE <br /> PHASE II G OU INSPECTION <br />'NS BY f PHASE III/FINAL INSPECT ON <br /> DATE INSPECTION BY DATE <br /> � r� �"� vi✓. "° 'f'�i'�'"'sr"'`r. - ` tea � ' <br /> E H11426 Rev. • 1--74 - f( �,�77 �n� � <br />