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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OE' OFFICE USE: 1601 E. Hazelton Ave. , •Stockton, Ca1i'f- <br /> Telephone: (209) 466-6781 APPLICATION FOR WELL CONSTRUCTION OR PUMP PE $CPN0 <br /> Termit No. �` ' U <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedil-77 <br /> ';-0.1A c4,>(%ohiplete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe <br /> and/br install the work herein described.. This application is made in compliance with San Joaquin '. <br /> County Ordinance No. 1862 d he ules an�jReati t an Joagrn Local. Health District. <br /> 44, <br /> AWC <br /> JOB ADDRESS/LOCATIO CENSUS TRACT } <br /> l <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License I Phone <br /> • s <br /> TYPE�OF WORK (Check) : NEW- WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT 21 �N <br /> i# 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 <br /> Domestic/private Drilled Dia, of Well Casing �, II <br /> Domestic/public Driven Gauge of Casing <br /> 0 Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Proltection,i, Rotary Type of Grout <br /> Disposal Other Other Information <br /> '`Geophysical. _ Surface Seal Installed By: <br /> PUMP ; INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP ;REPLACEMENT: 1r-z State Work Done' ,,,„;, <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> g <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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELLI!DRILLERS REPORT of the well and notify them before puttingthe 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 GR Ti G AND A FINAL 4SPECTIO . <br /> SIGNED _ TITLE _ 4 <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO VbEPART'MENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY 11 DATE , <br />,'ADDITIONAL COMMENTS: 77 v / <br /> ' PHASE I GROUT INSPECTION PHASE IIS'//FINAL IN PECT N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> U ,fr, j_ . <br />