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SAN JOAQUIN L' CAL HEAL TH.DISTRI T <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, ;Calif. <br /> �. 7� rDlTelephone: (209466fi781' <br /> APPLICATION FOR WELL CONSTRUCTION ORt P#W P RMIT ' ' " Petmit No. 2D lrJ <br /> I THIS PERMIT EXPIRES L YEAR FROM DATE ISSUER} Date Issued <br /> (Complete In Triplicate) xt <br /> Application is hereby made to the San Joaquin Local Health District_ for.,"'a'permit' to� construct <br /> Viand/or install the work herein described, ' This application is made. in compliance with San Joaqui <br /> County-Ordinance 'No, 1862 'and 'the Rules' and Regulations ,of th ' 'San. 3aagvin Local Heath District,. <br /> JOB ADDRESSILO O 73 _ <br /> ENSUS TRACT <br /> :Owner's .Na: <br /> rr�� <br /> Phone C <br /> Address <br /> City` <br /> Contractor's Name d _ <br /> .License Phone <br /> TYPE OF WORK (Check): NEW, WELL j DEEPEN /_7 RECONDITION /-7 ' DESTRUCTION f7 <br /> PUMP INSTAL TION / / PUMP REPAIR /=7 PUMP REPLACEMENT E7 <br /> Other L <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATED(}MESTIC 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 /> ,. <br /> -Domestic/public Driven Gauge=of Casing <br /> Irrigation ravel Pack Depth of Grout Seal <br /> Cathodic ProtectionR �Rotary Type of Grout <br /> Disposal - Other Other Information ,¢ i <br /> Geophysical Surface Seal Installed B <br /> 'PUMP INSTALLATION: Contractor ( <br /> i Type of Pump H.P. <br /> .PULP REPLACEMENT: /_7 State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> D S;T UCTION OF WELL: Well Diameter Approximate.Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all . <br /> p y laws and regulations of the San Joaquin Local Health District <br /> and the State of Californiapertaining 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- the -well. in.use,:.. above <br /> It information ,is true to the•best-of- my.,knowledge and belief. I LL L FOR 'A 'G SPECT <br /> UC— <br /> iPRIOR TO OUTING 'AND FIN INSPECTION. <br /> SIGNED 1 �. TITLE <br /> ` D W PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> ' APPLICATION' ACCEPTED BY <br /> DATE / <br /> ADDITIONAL COMMENTS: CZ1121, <br /> AIV <br /> � . PHASE II GROUT INSPECTION PHA E I FINALSPEw-;� <br /> INSPECTION BY DATE C;_ INSPECTION BY DATE <br /> b <br /> °. E .H' 1426 Rev. 1-74 a -Y u 1/75 <br />