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ALTH <br /> SAN JOAQUIN LOCAL MEStocktonTRCalif. <br /> FOfi OFFIGE USE: 1601 E. Hazelton Ave. , , <br /> Telephone: (209) 466-67$1 Permit No. <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> 7 f <br /> 44 <br /> THIS PERMIT E)CPTRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) it <br /> rict for a perm <br /> Application is hereby made to the San Joaquin Lo application iscal Health tmade in compliance twith SanuJoaquin� <br /> pP <br /> and/or install the work herein described. This application <br /> i Count Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Loca] Health District. <br /> County CENSUS TRACT 1 <br /> JOB ADDRESS <br /> r Phone <br /> Owner's Name <br /> f f city <br />+ Address <br /> License hone -�Z <br /> Contractor's Name - <br /> -. WORK Check): NEW WELL DEEPEN"" RECONDON f7 <br /> ITION [7 <br /> IEMENTT <br /> TYPE OF <br /> PUMP INST LATION PUMP REPAIR /� <br /> ,,-Other <br /> AllIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK '�0 SEWER LINE�SSPOOLISEEPAGE PIT �p�-OTHER <br /> C SEWAGE DISPOSAL FIELD_ PUBLIC DOMESTIC WELL <br /> PROPERTY' LINE -'PRIVATE If01+lESTIG{WELZ;CONSTRUCTION SPECIFICATIONS (� <br /> ` "INTENDED USE yTYPE OF WELL, <br /> Industrial !Y Cab 1e Too_1 , Dia ,,,Of Well Excavation <br /> t t—Domestic/private -. yDrilled- Dia. of GTe11 Casing G` <br /> Domestic/public Driven _ �f '. Gauge of Casing <br /> Irrigation �' Gravel Pack' Depth`of Grout Seal , <br /> e .of Grout ' , <br /> Cathodic Protection Rotary <br /> Disposal', Other Oer Information <br /> - <br /> Geophysical - Surface Seal Installed B : <br /> PUMP INSTALLATION. Contractor g <br /> H.P. <br /> Type of Pump <br /> 4 <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP :REPAIR: I / State Work Done " <br /> f DES+TRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe%.Material and Pxocediure <br /> I hereby agree to comply with all laws and-regulations of-,the San-Joaquin Local Health District <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 twill furnish. the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify Ithem before 'putting- the..well- in use.. . The above <br /> information is true to the-best•of .my..knowl.edge and belief. I WILL CALL FiGROUT INSPECTION <br /> ! PRIOR TO GROUTING AND A FINAL INSPECTION <br /> E <br /> SIGNED PLOT P ON REVERSE. SIDE <br /> FOR DEP TMENT USE ONLY <br /> PHASE I i DATE -:Ii <br /> APPLICATION ACCEPTED BY' <br /> ADDITIONAL COMMENTS: P 5 I I F INSPECTION <br /> PHASF, II GROUT- INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE, <br /> 2M <br /> n u •f I. fG n.�.. 774 <br />