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yam' r; <br /> FOA <br /> SAN JOAQU& -OCAL HEALTH DISTRICT <br /> R..©FFIG1� [!SE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'s -10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATZ,'ISSUED Date Issued <br /> I (Complete In Triplicate)[ <br /> Application is hereby made torthe Saiz Joaquin Local health Die'Itrict for a permit to construct <br /> and/or install the work herein described. This application is;;made in compliance with San Joaquin: <br /> County Ordinance No. 1862 and the Rules and Regulations of the�' San -Josquin Local Health District.. � <br /> JOB ADDRESS/LOCATION 7 �`� o - '�j CENSUS TRACT , <br /> I� <br /> Owner s Namei ! Phone , <br /> Address I� City' <br /> _44,fL 2 <br /> Contractor's Name Iicensejaf3 Phone <br /> TYPE'OF WORK (Check) NEW WELL �DEEPEN -/7 RECONDITION AL1r <br /> _T DESTRUCTION / <br /> PUMP INSTLATION '/ / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK dSEWER 'LINES Q" PIT PRIVY <br /> X�/ SEWAGE,-DISPOSAL FIELD CESSPOOL/SgEPAGE PIT OTHER <br /> . PROPERTY LINE - PRIVATE DOMESTIC WELL ®� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a 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 Protectiony Rotary Type of Grout k <br /> Disposal Other Other Information <br /> Geophysical Surface Se Al Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> C PUMP REPLACEMENT: . / / State Work Done. <br /> PUMP .REPAIR:.__ -=<:: .: / / -State-Work Done <br /> DESApproximate TRUCTION OF WELL: Well Diameter - � pp Depth <br /> Describe Material and Procedure <br />' I 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 " onstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the`kSan Joaquin Local Health District a <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 T9 GWUTING -AND A--MAL INS CTtO I� <br /> SIGNED ITL <br /> (DLOT P - O REV E SI ' <br /> RA <br /> OR DEPARTMENT USE ONLY <br /> 4 PHASE I <br /> APPLICATION ACCEPTED BY t i DATE ��"� <br /> ADDITIONAL COMMENTS: <br /> PHASE OUT NSPECTION j PHASE III/,FINAL INSPECTION <br /> k INSPECTION BY ATE _T- �► ` 76' INSPECTION ,BY G✓. DATE 5 <br />