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FOF OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif, <br /> ` Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �] <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued S <br /> (Complete Triplicate) ,71, <br /> Application is hereby made to' the San Joaquin Local HealthDistrictfor a permit to <br /> f and/or install the work herein described. This application construct <br /> County Ordinance No. 1862 and the Rules and Regulations of the SaneJoaquinpLocaliancealtHeSan Joaquin <br /> alth District, <br /> JOB ADDRESS/LOCATION f t <br /> CENSUS TRACT - S <br /> Owner's Name <br /> i <br /> Phone a <br /> Address ` <br /> city <br /> Contractor's <br /> Name <br /> _ I icense �f� Phone <br /> TYPE OF WORK (Check) : NEW WELL '� <br /> EEPEN /7 RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /- t <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> �_� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL- <br /> Industrial <br /> ELL <br /> INTENDED USE TYPE OF WELL y <br /> Industrial CONSTRUCTION SPECIFICATIONS <br />"�/I5'omestic/private Drilledd <br /> _ Cable VDia. of Well. Excavation (� <br /> p. • <br /> Domestic/public .Dia, of Well Casing - �`---Driven Gduge of Casing <br /> Irrigation Gravel Pack <br /> �Degth of GroutSealQ <br /> Cathodic Protection Rotary " � <br /> Disposal (. 'Type of Grout -- <br /> Other s Other` Information <br /> Geophysical m <br /> i Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump .� <br /> _'� H.P. <br />'UMP REPLACEMENT: <br /> State Work Done i <br />'UMP .REPAIR: State Work Doner <br /> f I k <br /> - t <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure i 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 well "construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish` <br /> ELL DRILLERS REPORT of the well and notify them before the San Joaquin Local Health District a <br /> nformation is true to the best of my knowledge and belieftingt - the- well in use. eabove <br /> 4IOR TO GRO TNG D A FINAL INSPECTION I WILL CALL FOR A GROUT INSPECTI <br /> IGNED � `` <br /> ' y TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />.SASE I FQR.,DEPARTMENT USE---------------- <br /> ONLY <br /> x <br />?PLICATION ACCEPTED BY � <br />]DITIONAL COMMENTS: ' t DATE <br /> PHASE. II GROUT INSPECTION <br /> dSPECTION BY DATE PHASE II/FINAL INSPECTION <br /> 7 INSPECTION; BYDATE <br /> E H 1426„ <br /> .Rev. • 1-74 <br />