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. SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE:, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209} 46-6791 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health 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. 1862 and the Rules and Regul tions of the San Joaquin Local Health District. <br /> r _ <br /> JOB ADDRESS/LOCATION .GAO CENSUS TRAGI ' <br /> Owner's Name Phone a— 6 r <br /> Address ��� ti(1 <br /> City j <br /> Contractor's Name <br /> .�� License 0�/_1j'_-j_Phone <br /> d <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 t <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 , <br /> Other <br />`DISfiANGE 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 3 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> a�Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing *�. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection __ 4rRotary Type of Grout <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal Installed By: --- <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . <br /> / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Materi'alland Procedure r x* <br /> I hereby agree to 'comply with all laws and regulations o.f-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 oii-a _neva well, I will furnish the`.San Joaquin Local"-Health-District a <br /> WELL DRILLERS REPORT._of-the.,well .and-.no.tify.them bef.or.e4�put,tirig the�Well-'fn.�use. The above <br /> information_ : is rue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ANkA YAVL INSPECTION. <br /> SIGNED _ TITLE <br /> :ITDRAW PLAN 'ON=RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � y <br /> APPLICATION AC bEPTED BY r DATE <br /> ADDITIONAL COMiENTS: <br /> P, SE II GROUT INSPECTWN -PHASE III/FINAL INSPEC 0 <br /> INSPECTION BY { DATE INSPECTION BY �- DATE <br /> H <br /> 2M <br /> 1426' Rev. 1-7476 <br />