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SAN JOAQUIN LOCAL DEAL SCANNED <br /> FOr�:OFFICE USE, � TH DISTRICT q <br /> 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 <br /> Date Issued _ _3___ <br /> Application is hereby made to the Saki (Complete In Triplicate)Joaquin Local 11calth District for a permit to construct <br /> land/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and � la o ps. ofl the ��gqui Local Health District. <br /> � rz <br /> JOB ADDRESS/LOCATION c� cENsys TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City ' <br /> Contractor's Name j r License ` <br /> TYPE OF WORK (Check)s NEW WELL/7 DEEPEN J_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /Vf_`"­PUNP REPAIR/_7 PUMP REPLACEMENT f_ <br /> Other /% <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 /> dustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ~� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otect_ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - <br /> i <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 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 is true to the-best-of- my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO- GROUT-1M-ANDA IN INSPECTION. <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE S E <br /> PRASE I <br /> FOR DEPARTMENT SSE ONLY <br /> ' <br /> APPLICATION ACCEPTED BY DATE . 7-/6- <br /> ADDITIONAL COMMENTS: __�4 . <br /> PHASE II GROUT INSPECTION P E I INAL INSPECTION. . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/7K 9M <br />