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- � ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F <br /> FOE OP, ICE USE. 1601 E. Hazelton Ave., Stockton, Calif. <br /> '`" Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> k <br /> THIS .PERMIT .EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete 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 Samoa- a <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Mer a rmom/t� <br /> CENSUS TRACT <br /> Owner's Name ~� Phone <br /> Address , <br /> "8 City . <br /> Contractor's Name License # /��hone .-.L'��&:74 <br /> t <br /> s,TYPE OF WORK. (Check) : NEW WELL /? DEEPEN /? RECONDITION �f DESTRUCTION /� <br /> AL ` <br /> PUMP INSTLATION PUMP REPAIR /C� PUMP REPLACEMENT /� CA <br /> Other <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD A CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL"- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation w <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public , Driven Gauge of Casing <br /> k Irrigation Gravel Pack Depth of Grout Seal <br /> E Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> r' Type of Pump H.P. 3 0 <br /> PUMP REPLACEMENT: . /�/ State Work Done <br />'4PUMP :REPAIR:- - - /x/ State-Work Don-e <br /> CSO h "'o,�' •. - <br /> DE&TRUCTION OF WELL: Well Diameter <br /> Describe,Material and Procedure Approximate Depth <br /> I hereby agree to comply with all Taws 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 will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify• them"before 'putting'the..well. in use... The above <br /> information is true' to the,best .of. my..know ge and belief. <br /> PRIOR TO GROUTINGAMn A FINAL I WILL CALL FOR A GROUT INSPECTION <br /> INS <br /> SIGNED �"� <br /> TITLE1', <br /> (DRAW LOT PLAN ON VERSE SIDE -. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> l <br />�'�ATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE / `-- <br /> PHASE II. 1tOUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE p <br /> INSPECTION `BY DATE <br /> E H 1426 Rev. 1-74 <br />