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SAN 'OAQUIN LOCAL HEALTH DISTRICT <br /> FOR,-OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE-ISSUED Date Issued <br /> (Complete In. Tripliate) <br /> Application is hereby made to the Son 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. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /.{J <br /> � � e�- O �C � CENSUS TRACT <br /> Owner's Name DEL. Phone . :. <br /> Address <br /> •.. . City':.- TRACY <br /> Contractor's Name # <br /> _ INTES 3R0S DIjjTNG C0_.a,.INC. License # ' 29083 Phone 522_-1011 <br /> RD. i MOD. <br /> TYPE OF WORK (Check)t NEW WELLLK7 DEEPENS/? f <br /> RECONDITION /? DESTRUCTION f <br /> PUMP INSTALLATION.-/� PUMP REPAIR'1_7 PUMP REPLACEMENT 9 <br /> Other / <br /> D S,.°!3�TO NEAREST: SEPTIC TANK __670 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL�� PUBLIC DOMESTIC WELL <br /> INTENDED USX TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> _ Industrial - Cable Tool Dia. of Well Excavation sr <br />_ X ' Domestic/private Drilled Dia. of Well Casing. b_ <br /> Domestic/public Driven Gauge. of Casing _ 2 <br /> Irrigation ..."� <br /> $ Gravel, Pack Depth of Grout Seal •.COs - <br /> .Cathodic Protection X . Rotary <br /> Type of Grout 'Bentonite <br /> Disposal Other Other Information Slab-- by owner <br /> Geophysical _r...__ <br /> - - _ Surface Seal Installed Bv: ' dri ler <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: . f/ State Work Done <br /> _ ..Ti <br /> PUMP .REPAIR: /7 ,State Work Done <br /> DESTRUCTION ,OF WELL: Well Diameter Approximate Depth r <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 well'construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the, well and notify. theta before putting..the. W811 in.use... The' above ' ' i <br /> information is true to the•best of• my knowledge and belief. I WILL CALL FORA GROUT INSPECTION f <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED . ,:INC. BY TITLE SEC. , <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> CHASE I FOR DEPARTMENT USE ONLY <br /> kPPLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE. II WUT INSPECTIO f PHASE III FINAL INSPECTION ; <br /> CNSPECTION BYDATE INSPECTION BY DATE <br /> , <br /> E H- 1426 " Rev. 1-74 1,179 glut ._�_ -4 <br />