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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO}'rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?Z �� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�-,/3-�� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct R3 <br /> and/or install thetwork herein described. This application is made in compliance with San Joaquin <br /> ations of the San Joaquin Local Health District. <br /> County Ordinance-No. 1862 and the Rules and Regul <br /> r <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Name Phone <br /> / <br /> Address S-G Z_- d! �0t�- City ' <br /> } <br /> License # ��� Phone <br /> Contractor's Name � <br /> TYPE OF WORK Check}; NEW WELL 4-T DEEPEN/? RECONDITION /� DESTRUCTION /^T <br /> G <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT /� ; <br /> Other F x' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �` p <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 �4 <br /> Industrial <br /> Cable Tool Dia. of Well Excavation _ � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal . _ Other <br /> Other Information <br /> Geophysical Surface Seal 'Installed By:. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ` PUMP REPLACEMENT: / / State Work .Done <br /> PUHP !REPAIR: / State Work Done <br /> ;DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure <br /> CI 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 /> WELL DRILLERS REPORT of the well and notify them before putting thewell in.use.. The above <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INS �ION <br /> PRIOR TO ROUTI G AND A FI AL INSPECTION. <br /> TITLE <br /> SIGNEDA= <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION // PHASE III FINAL INSPECTION <br /> INSPECTION BY _ i DATE INSPECTION BY ;2" DATE <br /> 1-74 2M <br /> 1E H 1426 Rev. 1-74 <br />