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FOh OFFICEUSE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton,..Calif. <br /> Telephone : 6 �0 <br /> APPLICATION FOR WELL CONSTRUCTION OR"PUMP .PE <br /> PUMP -PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED7 <br /> Date Issued/ <br /> Application is hereby made to the SanJoaquinComplete <br /> Lo alrHeplic <br /> althtDistrict for a permit to construct <br /> I and/or install the work herein describe <br /> County Ordinance No. I$62 and the Rul This application; is made in compliance with San Ja uin <br /> /' and gulations of a San, Joaquin Local Health District. <br /> f / <br /> JOB ADDRESS/LO TION �� J , <br /> � P_e__(CENSUS TRACT <br /> 'Owner's Nam J Phone <br /> Address. <br /> Cit <br /> Contractor's Name /�,� <br /> LicenseJ_3_,3 Phone <br /> TYPE OF WORK (Check) ; .NEW WELL / / DEEPEN <br /> PUMP INSTALLATION RECONDTTIO. / DESTRUCTION /? <br /> / PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -- PRIVATE' DOMESTIC WELL- PUBLIC DOMESTIC WELR <br /> INTENDED USE L <br /> TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS \ <br /> Domestic/private <br /> Cable Tool Dia, of Well Excavation <br /> Drilled <br />�� Domestic/public Dia. of Well Casing ' <br /> Irrigation Driven Gauge of Casing . Q <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary \ j <br /> Type of Grout <br /> Disposal <br /> Other Other Information <br /> Geophysical ----� <br /> Surface Seal InstalledB : <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump <br /> H.P. <br />'UMP REPLACEMENT / / State Work Done , <br />'UMP REPAIR:' Stave Work D <br /> cce <br /> ES•TRUCTION OF WELL: Well Diameter 4 <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating wei;l 'construction* Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of -the well and notify them before putting the- well in use. The above <br /> nformatioii is true to the best of. my knowledge and belief. <br /> tIOR'TO GROUTING AND I WILL CALL FOR A GROUT INSPECTION <br /> A FINAL <br /> IGNED INSPECTION. <br /> �� <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> iA.SE I <br /> FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: i DATE <br /> PHASE II GROUT INSPECTION PHASE I /FIDATE <br /> N INSPECTION r <br /> fSPECTION BY DATE INSPECTION BY <br /> E H -1426 Rev. 1-74 1 177 —, W <br />