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SAN- JOAQUIN LOCAL HEALTH DISTRICT <br /> ��R.OFFICE' USE• 160Stockton, Calif. <br /> .1 E. Hazelton Ave. , <br /> Telephone: (209).-4b6--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /���� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health <br /> isistmade infor <br /> compliance twithnSanuJoaquin <br /> and/or install the work herein described. This applica 11 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT . <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's. Name J 12 A 4 <br /> Address <br /> �'�� ,J d � - r,���► � city .v ®n <br /> 7`� License #2_2Phone.Z/-, <br /> Contractor's Name / <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /,RECONDITION /� DESTRUCTION _ <br /> PUMP INSTALLATION./ / PUMP REPAIR'/ / PUMP REPLACEMENT I�T <br /> Other / / <br /> DISTANCE T0._NEAREST:.�SE �CTANK !r SEWER LINES S?J PIT PRIVY <br /> ISPO AL FIELD I_.sJ_�_ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL PUBLiC DOMESTIC WELL <br /> � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of -Well Excavation C/ <br /> Well Casing <br /> f W <br /> o <br /> , eg ` <br /> ' Domestic/private Drilled � Dia <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal V <br /> Cathodic Protection Rotary Type of Grout \ <br /> Disposal Other Other Informaf.ion <br /> I Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUAP ,,REPAIR: / / State Work Done �\ <br /> Approximate Depth <br /> DES-TRUCTION OF WELL: Well Diameter <br /> \ <br /> Describe Material and Procedure <br /> 1 I hereby agree to comply with all laws and regulations of the San District <br /> Joaquin Local Health <br /> and the State of California pertaining to or regulating well .eonstructian. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local.-Health District <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 INSPECTION <br /> PRIOR TO GROUTING D A FINAL INSPECTION. TITLE <br /> I SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT. USE ONLY <br /> PHASE I DATE //- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p I /FINAL INSPECTION ' _ .$ <br /> TA�GROUT INSPECTION DATE <br /> INSPECTION. B —.DATE, �1- � INSPECTION _BY..- n <br /> U IL?A Rev_ 1-74 <br />