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M1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: .1601 E. Hazeltcm Ave: , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6-S� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e-6-n # . <br /> (Complete, In Triplicate) <br /> Application is hereby made to the San Joaquin Local stealth District 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. 1.862 and th Rules and Regulations of theSa ;Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name - Phone 49 <br /> Address <br /> City <br /> Contractor' Name License # /d %yPhone '! <br /> TYPE OF WORK (Check): NEW WELL ,/7 DEEPEN '/ RECONDITION- f DESTRUCTION <br /> PUMP INSTALLATION /_/ .PUMP REPAIR -/-7—pump REPLACT , � k <br /> Other <br /> DISTANCE 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 <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 Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed t3 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: - / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> A pro mate Depth <br /> De ribe Material and Procedure ` <br /> I hereby agree to comply with all and regulations of the San -Jo9q,01n Local Health-District <br /> and'.the.State_of,-_California :pertaik ng' to_.o7 regulating-well "constru 'ion. Within FIFTEEN DAYS <br /> after completion of any work on a new well, I will furnish the San Joaq it 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-be st'of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> m <br /> PRIOit TO G OU LNG A FINAL SP IO <br /> SIGNED _ -TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> •', . <br /> APPLICATION ACCEPTED BYDATE ' <br /> ADDITIONAL, COMMENTS: r <br /> PHASE II GROUT INSPECTION _ P I NAL IN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-76 r ," . 1.lit om 4 <br />