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• <br /> SAN JOAQ ALTH DIS RICT,� <br /> 0 OFFICE USE: 1601 E. Hazelton Ave,. ;,t, Stockton, Calif. <br /> Telephone: (209) 466-6181 <br /> Al tl. J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , 3� <br /> THIS PERMIT EXPIRES 1 YEAR FROM.DATE.'ISSUED Date Issued ' <br /> (Complete In Triplicate). <br /> Application is hereby made to the Sun Joaquin,Local TTealth District for a. permi,t 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. Ruies' and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Ownera Name `° Phone _ . . <br /> Addyress <br /> City 7 <br /> Contractor's NameIf"tao License-# Phone / <br /> TYPE OF WORK (Check): NEW WELL /F'DEEPEN/-7 RECONDITION /7 .DESTRUCTION /7' <br /> PUMP INSTALLATION / /7 PUMP REPAIR 1-7 PUMP REPLACEMENT f7.. <br /> Other /� .. ... <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial '.. Cable Tool Dia. of' Well Excavation <br /> / Domestic/private Drilled Dia. of Weld., in <br /> Casg,. •� Y.. ._.. <br /> Domestic/public Driven `-Gauge of Casing `� Q <br /> Irrigation Gravel Pack Depth of Grout Sear _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 'IT <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> f Type .of Pump R.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /_ State Work Done <br /> DES-TRUCTION -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.'Vell. in.use.. : The above. <br /> information is true to the-best-of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION` <br /> PRIOR TO GROUTING ANDA NAL INVECTXON. <br /> SIGNED TITLE ' i <br /> D PLOTJPLAN ON REV RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP.PLICATION' ACCEPTED BY DATE i Z-2 7 <br /> ADDITIONAL COMMMS: <br /> PHASE 11 PROUT INSPECTION PHASE I 1 FIlE INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E'H 1426 Rev. 1-74 _. /75 ;2M�'— <br />