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FOAi0FFICE USE; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Telephone: Stockton, Calif. <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT x <br /> THIS PERMIT EXPIRES .. Permit No. <br /> APPiieatioa is hereby 1 Y FROM DATE ISSUED <br /> (Comp3,ate in Triplicate) Date Issued made to the San Joaquin Local Health District for a e <br /> and/or Install the work herein described. <br /> County Ordinance No. 1862 and the Rules with <br /> andTResulatffcation is made in complianceP permit to const <br /> Regulations of the San JoaquiLolHealth San <br /> Joaquin <br /> JOE ADDRESS/LOCATION <br /> Owner's Name �O CENSUS TRACT - Z! <br /> Address Phone <br /> Contractor's Name City - <br /> License Phone ? 1;- <br /> TYPE OF WORK (Check): NEW WELL <br /> jTlw DEEPENJ-7/? RECONDITION <br /> PUMP INSTALLATION / / PUMPREPAIR L-7—Pump REPLACEMENT— <br /> Er <br /> Other <br /> / / <br /> DISTANCE TO N <br /> EAREST: SEPTIC TANK /� <br /> X SEWAGE DISPOSAL FISS�Ij LINES ��� . PIT PRIVY <br /> PROPERTY LINE -- PRIVATE MESTICSWE SEEPAGE PITOTHER <br /> INTENDED USE PUBLIC C WELL <br /> Industrial TYPE OF WELL eti <br /> Cable Tool CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Dia. of We11 Excavation <br /> of <br /> /Public , f <br /> Domestic -..�_ Drilled Dia. of Well Casing <br /> �� <br /> Irrigation Driven Gauge of Casing �f <br /> Cathodic ProtectionGravel Pack Depth of Grout Seal, , 7S ; <br />"--.Disposal � Rotary � <br /> Other Type of Grout <br /> Geophysical _.._-- Other Information <br /> PUMP INSTALLATION. — <br /> Surface Seal Installed B <br /> Contractor <br /> Type of Pump -� <br /> PUMP REPLACEMENT: H.P. <br /> State Work Done <br /> P-tTMPr'REPAIR. /-7,.�S.tate-Work-Donexz� <br /> ... "'""„"'tet':. -ter.•.._j.-�--..-�.�-.�;.--. <br />)ES.'TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local Health <br /> Ind the State of California pertaining to or regulating well construction. <br /> after completion District ' <br /> P f my work on a new well, I will furnish the San Joaquin LocalWithin HealthTDistrict a <br /> nfoFELL Dation' S_REP RT, of, the well and notify them before Putting.. the..well in use.. <br /> nformatiorx �s fru to .the•best-of. m <br /> RIOR TO `G OUTING j' Y knowledge and belief. The above <br /> D., FINAL SPECTION. I WILL CALL FOR A GROUT INSPECTION <br /> IGI4ED <br /> W PLO PLAN QN TITLE ? ! <br /> FOR DE ERSE SIDE) <br />:SASE I <br /> SE ONLY <br />°P CIL ATION ACCEPTED <br />}DITIONAL CO NTS: fZT S,I� DATE <br /> P I ROUT INSPECTIO <br />[SPON By DATE - I AL INSPECTION <br /> 7 INSPEC DATE <br /> E H 1426 Rev. 1-74 <br />