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Z1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 /J. <br /> I' - I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��t 7S" <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local 11ealth 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 Rules and Regulations of the San Joaquin Local Health District.� � <br /> 1 .2 P 9/ W& t <br /> JOB ADDRESSJLOCATION fs CENSUS TRACT <br /> fOwner's Name Phone ' ^� <br /> Address <br /> k Cit <br /> y <br /> Contractor's Name ' 6License lyf Phon <br /> TYPE OF WORK (Check) : 'NEW WELL /_7 DEEPEN '/? RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION ISI PUMP REPAIR ' PUMP REPLACEMENT 17 <br /> Other' / -/ , <br /> ti <br /> DISTANCE TO NEAREST: SEPTIC -TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER .?lj <br /> PROPERTY LINE =PRIVA"TE DOMESTIC WELT ' 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 f <br /> -,Irrigation Gravel Pack Depth of Grout Seal <br /> ''~Cathodic Pr-otection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: .._ <br /> PUMP. INSTALLATION: Contractor s} <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: . State Work Done _ _ . <br /> PUMP (REPAIR: 1 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure y . <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,'constructi:on. Within FIFTEEN DAYS N <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. ' A WILL CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO TI G AN INAL INSP ION. <br /> SIGNED <br /> TYTLE <br /> DRAW PLt}T PLAN ON REVERSE SIDE <br /> + <br /> PHASE I R DEPARTMENT USE :ONLY <br /> � -APPLICATION ACCEPTED BY DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - PHASE,-1IFI AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> f <br /> R H. 14126 Rev. 1-74 i ` <br />