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SAN JOAQUIN LOCAL IiFALTH � - -_.--- <br /> FaP1(Q0CE USE: DISTRICT <br /> 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (201) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�9)4v <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Z_ <br /> (Complete in Triplicate) <br /> Application is hereby made to the Sat: Joaquin Local Health District for a permit to construct <br /> i 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 JoaquinLocal Health District. <br /> ;TOB ADDRESS/LOCATION �� �� AuA ENSUS TRACT <br /> k <br /> Owner r s Name Phone <br /> Address <br /> - ty <br /> Contractor's Name License # � <br /> -`Phone <br /> t <br /> 'TYPE d_F WORK­ (Check)': NEWTWELL_/7 DEEPEN '/_/ RECONDITION /'7 DESTRUCTION /—j <br /> PUMP INSTALLATION PUMP REPAIR �/ PUMP REPLACEMEENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia. of Well Excavation d <br /> Domestic/private Drilled Dia. of Well Casing d <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout l� <br /> Disposal _ Other Other Information <br /> " Geophysical - - — <br /> SurSeal Installed B �[ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State work Done <br /> PUMP .REPAIR:... /We State Work Done <br /> �.. . _ ' . <br /> ES�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material, and Procedure <br /> I hereby agree tocomply 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 a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting..the..well in.use.. The above <br /> information i true to the-best of my knowled fid b ef. I WILL CALL FOR Ar GROUT INSPE TION <br /> PRIOR T - INQ AND A FINAL SPE ION;O,, f <br /> SIGNED <br /> TLE <br /> C r PL ON SE SIDE <br /> PRASE I AR.DEPARTMENT USE ONLY j <br /> APP-A TON ACCEPTED BY DATE �•—!�d `�� ' <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION P S /FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE �� # <br /> E H 1426 Rev. 1-74 <br /> 1-74 9M <br />