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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR .O�`F10E USE: ' <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 7 <br /> Application is hereby made tothe San (.7oaquineLo aI In rHealth iplicatD rict) <br /> a permit <br /> and/or install the work herein described. This application istmade inrcompliancetwithnSan uJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION //[o r� 0 <br /> CENSUS TRACT <br /> Owner's Name J <br /> a <br /> 100, <br /> Phone <br /> Address <br /> I <br /> City <br />( Contractor's Name <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL "/ / DEEPEN _ <br /> RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other / / / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- OTHE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELP <br /> L U <br /> TYPE OF WELL "LIC DOMESTIC WE L <br /> INTENDED USE <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of We11 Excavation <br /> Domestic/private Drilled <br /> Domestic/public Dia. of Well Casing <br /> Irrigation �' Graven Gauge of Casing <br /> Gravel Pack <br /> Cathodic Protection Rotary Depth of Grout Seal <br /> Disposal Type of Grout , <br /> Geophysical --- Other Information <br /> Surface Seal Installed B : � (` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br />'UMP REPLACEMENT State Work Done <br /> Ap <br /> S r," <br />'UMP ,REPAIR: . <br /> State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter, <br /> Describe Material andProcedure Approximate Depth <br /> -- � <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 wi11 furnish the San Joaquin Local Health District a <br /> ELL DRILLERis true of the well and notify them before putting the. well FOR <br /> n use. The above <br /> nformation is true to the best a£ my. knowledge and belief. I WILL CALL A GROUT INSPECTION <br /> tIOR TO GROU G Amr, A FINALILNNSPE IO <br />[GNEDOF <br /> TITLE it . <br /> (DRA PLOT PLAN ON REVERSE SIDE) � �' <br /> SASE I <br /> FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE I/F INSPECTION <br /> fSPECTION BY DATE2�&_ INSPECTION BY <br /> DATE�2_ <br /> E H 1426 Rev. 1-74 <br />