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F <br /> FOH O-O - SAN JOAQUII LOCAL HEALTH DISTRICT J <br /> FFICE USE 1601. E. Hazelton Ave;, Stockton, Calif. /V <br /> � ��, <br /> Telephone : <br /> APPLICATION FOR WELL CONSTRUCTION 6ORIPUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued � <br /> Application, is hereby made to the San (Compl <br /> J aquineLocalriplicateHealth District for aermit to <br /> E and/or install the work. herein described. This application is made in compliance with San <br /> P construct <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health DistrictJoaqus <br /> JOB ADDRESS AOCATION <br /> CENSUS TRACT - <br /> Owner's Name ? <br /> Address <br /> Phone �pl� <br /> City ° <br /> Contractor's <br /> Name ` - w '.:-„- ,_ <br /> 4 _ License �tone,a6? <br /> TYPE OF WORK (Check) : NEW WELLb(Y DEEPEN _ <br /> /% RECONDITION /% DESTRUCTION /_]" <br /> PUMP INSTALLATION 9/ , PUMP REPAIR / / PUMP REPLACEMENT -7 <br /> Other Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> jb_rte SEWER LINER PIT PRIVY <br /> ,. _ SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTICWEL <br /> HER <br /> INTENDED USE TYPE OF WELL `~ <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation a <br /> .Domestic/ : <br /> tic/private Drilled y� <br /> Dia. of Well Casing 'j" <br /> Domestic/public Driven <br /> Irrigation Gauge ofCasing <br /> Cathodic Protection <br /> Gravel Pack Depth- of Grout Seal <br /> Rotary Type of Grout <br /> Disposal , Other <br /> Geophysical �______,__ Other Information _ <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: f <br /> Contractor w <br /> Type of Pump . <br /> usn <br /> H.P. . <br />?UMP REPLACEMENT: <br /> / / State Work Done <br />'UMP .REPAIR: / / State Work Bone­ - - .-f-M --- <br /> s <br /> iESTRUCTION OF WELL: Well Diameter' <br /> f Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to #comply with all laws and, regulations of the San Joaquin/Local Health <br /> nd the State of California pertaining to or-re .Matin _ District <br /> fter compleEEN DAYS <br /> tion of my work on a new well, I will furnishethe cSan tJoaquin,LocalhHealth in TDistrict a <br />'ELL DRILLERS REPORT of the well and notify them before putting the well in use. . The above <br /> reformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GR UTING AT'Tn A INAL INSPECTION. <br /> 1GNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ��' � -- <br /> IASE TMENT USE_ONLY + ' <br /> PPLICA-T-ION--ACCEPTED-BY-C._.. __ _ , <br />)DITIONAL COMMENTS: DATE'.1 6 -7 <br /> PHASE II GROUT INSPECTION <br /> JSPECTION BY PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY <br /> DATE <br /> at <br /> E H 1426 Rev. . 1.-74 <br /> o�7 7 :` �nA <br />