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SA JOAQUIN LOCAL. HEALTH DISTRICT jam` <br /> ?OE.OFFICE USE: ' 1601 L P Hazelton Ave. , Stockton, Calm <br /> Telephone : (209) 466-6781 v�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUF,� Date Issued-3-4 -7/ <br /> (Complete In Triplicate) <br /> )plication is Aereby made to the San Joaquin Local Health District'f or mit o construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin <br /> )unty. Ordinance No.. 1862 <br /> and the Rules and Regulations of the San Joaquin Local Health Distract. <br /> )B ADDRESS/LOCATION D CENSUS TRACT <br /> I <br /> rner's NamePhone <br /> z <br /> .dress City ' ' <br /> intractor s NameLicense Phone <br /> d' <br /> f i <br /> :PE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> .STANCE 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 _ <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 Other Information <br /> Geophysical Surface Seal Installed BY: <br /> _NSP INSTALLATION: ContractorC <br /> Type of Pump ' n H.P, <br /> IMP REPLACEMENT: : State Work Donal � a_.C_ c.c� � <br /> 'MP .REPAIR: / / State Work Done <br /> 'SjRUCTION OF WELL: - Well Diameter Approximate Depth ' - <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> td the State of California pertaining to or regulating well•'construction. Within FIFTEEN DAYS <br /> ;ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> :LL DRILLERS REPORT of the well and notify them before putting the well in .use. The above <br /> iformation is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TOOUTING FINALINSPECTION. <br /> i GNED TITLE _ _-••- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ASE I <br /> PLICATION ACCEPTED BY DATE 3 <br /> 3DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I/FINAL INSPECTION <br /> 'ISPECTION BY DATE INSPECTION BY DATE <br /> i <br /> 2K W <br /> f E H 1426 Rev. 1-74 111 _ <br />