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SAS' 'OAQUiN LOCAL HEALTH DISTRICT <br /> FF OFFICE USE: 1601 N.• Hazelton Ave. , Stockton, Calif./ <br /> Telephone: (209) 466-6781 p _ <br /> - / APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-// - 73 <br /> (Complete In Triplicate) <br /> Lication is hereby made to the Sari Joaquin Local Health District for a permit to construct <br /> -r/or install the work herein described. This application is made in compliance with San Joaquin <br /> inty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ADDRESS/LOCATION �i` ` Al 9.2CENSUS TRACT <br /> ,r's Name Phone <br /> ress �l ,. —__- City --- <br /> .ractor's Name , License <br /> / tc y��Cyhone <br /> OF WORK (Check) : NEW WELL /L7—DEEPEN /-7 RECONDITION /_/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT / / <br /> O ther <br /> -ANCE 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 f,f <br /> /Isomestic/private Drilled Dia. of Well Casing +�" <br /> Irrigation <br /> Driven _-1119— <br /> --- <br /> Domestic/public Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal de <br /> Cathodic Protection Mary Type of Grout f <br /> -Disposal Other Other Information <br /> nformation <br /> Geophysical Surface Seal Installed By: <br /> " INSTALLATION: Contractor <br /> Type of Pump --- H.P. -- <br /> P REPLACEMENT: / / State Work Done <br /> REPAIR: / / State Work Done <br /> IUCTION OF WELL: Well Diameter _ Approximate Depth - <br /> Describe Material and Procedure - <br /> reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> :he State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 7-r completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> rmation is true tb the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> TR TO GROU NG D A FINAL INSPECTIU <br /> QED 'TITLE <br /> �DIWWILOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 3E I <br /> [CATION ACCEPTED BY DATE <br /> -emCIONAL C-OMN. ENTS: -- <br /> PHASE II OUT INSPECTION PHASE III/FINAL INSPECTION <br /> ACTION BY DATE INSPECTION BY DATE "° .' <br />