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FOP,OF CE USE: _S` N JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: „(209) 4661-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued Z----_7 <br /> Application is G reby made to the San Joaquin Local Health ,District for a permit to <br /> struct <br /> and/or install the work herein described, <br /> County,Ordinance No. 1862 and the Rules andTRegulationstofnthe Sanis eJoa compliance with nSan Joaquln <br /> Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Som <br /> CENSUS TRACT <br /> Owner's Name :,.•..� <br /> Phone <br /> Address- _ .. �, <br /> City <br />` Contractor's Name <br /> License # phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPENS'/ IDESTRUCTION /� <br /> Other / RECONDITION _ i <br /> ^T <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /� <br /> s <br /> DISTANCE TO NEAREST: SEPTIC ANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD. CESSPOOL/SEEPAGE'P ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTICWELL ' <br /> �EI,- <br /> INTENDED USE TYPE OF WELL <br /> Industria? CONSTRUCTION SPECIFICATIONS <br /> Domestic Cable Tool Dia. of Well Excavation t <br /> /private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven � <br /> Irrigation Gauge of Casing <br /> Gravel Patk Depth of Grout. S <br /> Cathodic Protection eal <br /> Disposal Rotary Type of Grout <br />_•Geophysica.l Other Other Information r�f <br /> IVa <br /> Surface Seal Installed by:- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> 'rs H.P. . . o o <br /> PUMP 'REPLACEMENT: <br /> Ll State Work Dane <br />'UMP :REPAIR: <br /> State Work Done / t <br /> iES!TRUCTION OF WELL Well Diameter <br /> Approximate Depth } <br /> Describe Material and Procedure <br /> hereby agree to comply with all Taws and regulations of the San Joaquin Local Health <br /> nd the State of California pertaining to or regulating well "construction. Within FIFTEENDAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before <br /> nformation is true to the best Of <br /> m Putting the- well in use. The above <br /> tIOR .TO GROU NG AND no ledge a belief. I WILL CALL FOR A GROUT <br /> A FINAL INSPE '�0 INSPECTTON <br /> IGNED <br /> TITLE d, <br /> {D W T LAN ON FRSE SIDE) <br /> iASE I FOR DEPARTMENT USE ONLY . <br />'PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSP CTION <br /> ISPECTION BY _ DATE PHA AL INSPECTION <br /> INSPECTION BY DATEH 1426 G: ' <br /> Rev. 1-7.4 <br />