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FOR SAN JOAQUIN LOCAL HEALTH DISTRICT - v--� <br /> 4 rOFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. s � <br /> LE <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued �� <br /> # (Complete In Triplicate) /C7- 1 <br /> gication is hereby made to the' San Joaquin Local Health District for a permit4�b o <br /> and/or install the work herein described. This application is made in compliancewith <br /> Jo <br /> County Ordinance No. 1862 and the Rules and .Regulations of the San Joaquin Local Health District. <br /> _ n Joaquin <br /> JOS ADDRESS/LOCATION ��- f <br /> i CENSUS TRACT�A. <br /> Owner's Name <br /> Phone <br /> Address <br /> Contractor's Name # City <br /> License _L2 <br /> Phone <br /> TYi'EY.OUWDRiC a(Che ck): .. .NEW:WELL <br /> -�- CONDITION�/_7 DESTRUCT-ION w <br /> PUMP INSTAIXATION :: <br /> /� PUMP REPAIR /� PUMP REPLACEMENT %( - <br /> Other /J f,. _� <br /> DISTANCE TO NEARE5T: SEPTIC TANK �r� tigR LINES. <br /> SEWAGE DISPOSAL FIELD J �'--� 'IT PRIVY <br /> CESSPOOL/SEEPAGE PIT <br /> PROPERTY-LLM PRIVATE DOMESTIC'`WELL OTHERINTENDED USE TYPE-OF WELL PUBLIC DOMESTIC WELL <br /> Industrial �� 'CONSTRUCTION SPECIFICATIONS <br /> { Cable Tool Dia. of Well Excavation <br /> Domestic/private � ,.Drilled �'� <br /> Domestic/public Dia. of Well Casing <br /> F Driven�j # Gauge of Casing ; <br /> Irrigation Gravel Pack , <br /> Depth of Grout <br /> -- Seal <br /> Cathodic Protection Rotary A -�_ <br /> Disposal TYPe-o.f-Groe�t <br /> Other <br /> Geophysical' �. :�---_" -T ------- -Othe.rff_ormatiaII <br /> Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor <br /> Type Ook Pump <br /> c* H.P. <br /> PUMP REPLACEMENT.': <br /> , . /�/. State Work Done J , <br /> PUMPr <br /> REPAIR. / Sate Work Done <br /> --� ��r <br /> 3E5RU <br /> �TCTION OF .WELL: Well blameter f <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply withfall laws ,and regulations of the San Joaquin Local Health Di <br /> and the State of of my rxiia 'pertaining to or regulating well construction. Within FIFTEENDAYSafter completion of my work 'ori" a new well, I will furnish the Sail Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in use.. <br /> information is true to the best--af.:my knowledge and belief. I WILL The above <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. CALL FORA GROUT INSPECTION <br /> SIGNED <br /> TITLE <br /> r s' (DRAW-PLOT_PL 11 -REVERSE SIDE) - --•--- <br /> �.E -.FOR-DEPART <br /> PHASE _ -.: ' _ MENT_USE-.ONLY:� <br /> APDL CATION ACCEPTED jBY' F � 2 Geo <br /> ADDITIONAL_COMMENTS.:_- _ -#� ..---_ DATE %� b <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE SE II INAL INSPECTION <br /> _. INSPECTION BY DATE -2,6 <br /> E H 1426 Rev. 1-74 <br />