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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE. ' 1601 E. Hazelton Ave. , ,Stockton, Calif, <br /> Telephone : (209) 466-6781 <br /> R PUMP PERMIT Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION O <br /> x "W � <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is Hereby made to the San Joaquin Local Health District <br /> and/or install the work herein described. This application is made inrcompliancetwith nSanuGt <br /> Joaqui <br /> County Ordinance No. ,1862 and the Rules and Regulations of the San Joaquin Local He trictn <br /> alth District.. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name ✓�« / <br /> ,. Address s � .o�. ,�,* • � , ,, '`- •� Phone <br /> ,- City <br /> Contractor's Name ` <br /> ...: L- cense•Y46 azo` hone <br /> TYPE OF WORK (Check) : NEW WELL DEEPENRECONDITION / / DESTRUCTION /7 <br /> PUMP{INSTALLATION /jQ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPPIC 'TANK� � <br /> *� <br /> _ / p- *SWERLINES �}. PIT PRIVY <br /> SEWAGE {DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE,�pPRIVATE DOMESTIC WELL PUBLIC OTHER <br /> INTENDED USE TYPE'OF WELL DOMESTIC WELL <br /> Industrial CONSTRUCTTON SPECIFICATIONS <br /> Cable Tovf Dia. f¢Well Excavation _.p <br /> Domestic/private Drilled Well Casing f�. <br /> Domestic/public +, <br /> f Driven: r : ; - <br /> Irri,gation� - Gauge of Casing <br /> Cathodic Protection. <br /> Gravel Pack Depth of Grout Seal <br /> , _ Rotary ' Type of Grout <br /> L, _'Disposal -L - .other � ,. ; <br /> Geophysical -- ' Other Information\i Sur <br /> Surface Seal Installed .B <br /> PUMP INSTALLATION M , <br /> 5 "`Contractor � , Ilk <br /> --Type of Pump `� z . !fir 7 w <br /> t H.P. <br /> PUMP REPLACEMENT: ' <br /> State Work Done <br /> PUMP °REPAIR: w <br /> State Work Done -e <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and/Procedure Approximate Depth <br /> T hereby agree to -comply with all laws and regulations of the San Joaquin Local Health istrict <br /> and the State of California pertaining to_ or:'ze ula.tin <br /> after completion of my work on a new well, I will furnishethe cSan tJoaquin.Local WithHealth Din istrict <br /> WELL DRILLERS REPORT of e ell and notify ,them before putting the- Well in use. The above t <br /> information is true t f my k ledge-and.x.be1-i.ef_,.. _ . _... <br />'RIOR TO GRO TWILL,-CALL FOR A GROUT INSPECTION 9 <br /> SIGNED INS P T <br /> TITLE f <br /> �( LO PLAN ON REVERSE SIDE.)__ �—� <br />?RASE I FO EPARTME_NT_ USE-'ONLY <br /> O'PLICATION ACCEPTED BY <br /> LDDITIONAL COMMENTS: DATE <br /> P'HAS S ON <br /> INSPECTION BY EI SPEC ON <br /> 1% ~ <br /> % INSP L TIO DATE j <br /> �. P � i <br /> 1426 Rev. 1-7 <br />