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FOE OFFICE USE: JOAQUIN LOCAL HEALTH DISTRICT <br /> SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _1,6y <br /> Ce THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate)r­ <br /> Application is hereby made to the San Joaquin Local Health Dis.trict 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 Regulations of the San Joaquin Local Health 'Distri.ct. , <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address ! *7 tf <br /> City <br /> Contractor's Name License Phone / <br /> IL <br /> TYPE OF WORK (Check)_:` NEWIWELL / / DEEPEN '/—/ RECONDITION / / DESTRUCTION /7 P <br /> PUMP INSTALLATION '/ / PUMP;REPAIR / / PUMP REPLACEMENT— <br /> __—Other' <br /> EPLACEMENT j. <br /> ...,�..,..._ —Other <br /> DISTANCE TO NEAREST:-: SEPTIC�TANK-- ---f-W-- SEWER-LINES. <br /> IT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL '. 1 . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool „ Dia. of Well Excavation p <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing (,a <br /> Irrigation Gravel Pack ' Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical. Surface Seal Installe�d7'B : <br /> i <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , /_7 -State Work`-Do_he,_'"_ <br /> PUMP .REPAIR;-- -�" - - �� � f <br /> / / State Work Done <br /> DES-TRUCTION OF WELL Well Diameter { <br /> Approximate Depth � <br /> Describe Material and Procedure <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 weld"construction. Within FIFTEEN DAYS <br /> after completion of my work on a 'new well, I will furnish the. Sari',,Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them .before putting the.`.`-,�ell in use. The above <br /> information is true o the best of- my..knowledge and -belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO OUTING IN INS ECTION. <br /> SIGNED TITLE <br /> D W P' T' PLAN 'ON REMSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - t DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PWR IU6 INSPECTT <br /> GN <br /> INSPECTION BY DATE INSPECTION DATE � <br /> E H 1426 Rev. .1-74 3/76 <br />