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FOE� AN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;OFFICE USE; 1601 E. Hazelton Ave, , Stockton, Calif. <br /> r <br /> Telephone: <br /> APPLICATION FOR WELLCONSTRUCTION 6OR1PU14P PERMIT Permit No. ; <br /> THIS PERMIT EXPIRES I YEAR FROM DATE -ISSUED <br /> Date Issued __12 _ <br /> (Complete In Triplicate) <br /> Application is hereby made to the Scan Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San-Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t, C W <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone - w <br /> Address <br /> City , <br /> Contractor's Name I l License DCfPhone _S�,f6 <br />�n TYPE OF WORKCheck � . . , <br /> ( } NEW WELT;"`/� YDEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> P.UMI?` INSTALLATION / / PUMP REPAIR ./? PUMP REPLACEMENT /7 <br /> M 3 — <br /> Otherr/%' <br /> } i <br /> DISTANCE TO NEAREST: SEPTIC-: TANK <br /> SE _L PIT PRIVY <br /> SEWAGE DISPOSAL FIELD "CESSPOOL/SEEPAGE PIT— OTHER <br /> PROPER7'YL1NE PRIVATE DO <br /> IN ENDED USE MESTIC WELL PUBLIC TIC WELL <br /> TYPE--OF WELL DOMES- { <br /> Industrial— CONSTRUCTION SPECIFICATIONS <br /> Cable Took-9 -'' Dia. of Well Excavation <br /> Domestic/private Drilled. ' ° Dia. of Well Casiri , <br /> Domestic/public f` g <br /> Irrigation ---�. Driven ;_ rt Gauge of Casing <br /> Gravel Pack 'Depth-of Grout <br /> ._ Cathodic Pr . <br /> otection Rotary . ' ' TySeal <br /> Type of :Grout <br /> —Disposal <br /> Other <br /> ______Geophysical Other Information <br /> Surface Seal Installed B <br /> .t` } <br /> PUMP INSTALLATION: Contractor <br /> Type of. Pump <br /> H.P. <br /> PUMPTREPLACEMENT: State Work' one <br /> z <br /> PUMP '-REPAIR: _._ <br /> / /. :State Work�Done_ t. <br /> DESTRUCTION OF WELL:, `}:Well Diameter - <br /> .ioDescribe Material and Procedure Approximate Depth <br /> I hereby agree to compl: rwWith all Laws and regulations of the San Joaquin Local Health Distri <br /> and the State of California pertaining 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.... The above <br /> information is true to tile-best,of my..knowledge and belief. I WILL CALL FOR A GROUT <br />'RIOR TO GROUTING 'AND 'A FINAL INSPECTION. INSPECTION <br /> SIGNED <br /> .�. TITLE <br /> ,DRAW PLOT PLAN ON REVERSE SIDE <br /> ( <br /> ' FOR DEPARTMENT USE ONLY <br /> PHAS:� �I � � .. -, <br />�',PLICATfOI� 'ACCEPTED BY _ G <br /> ,L/—76 <br /> ADDITIONAL <br /> DATE.COMMENTS: r� �. <br /> PHASE II.GROUT INSPECTION <br /> MPECTION BY DATE PHASE 'II FINAL INSPECTION <br /> INSPECTION BY DATE/_,l-cr <br /> EH 1426. <br />_.: Rev. 1-74 <br />