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4 / SAN JOAQUIN LOCAL HEALTH. DISTRICT � � �`��' <br /> FOE OFFICE USE: �/ 160 . E. Hazelton Ave. , Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL�CONSTRUCTION OR PUMP PERMIT Permit No. A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7~ 99p <br /> =�77 <br /> (Complete In Triplicate) <br /> i Application is hereby made to the San Joaquin Local Health District for a permit 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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/SON CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name License Phone ' <br /> s <br /> TYPE OF WORK (Check) : NEW WELL/ '. <br /> / / RECONDITION %/ DESTRUCTION /_7PUMW DEEPEN <br /> a.P INSTALLATION '/'g PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other/ / .. <br /> ti <br /> DISTANCE TO NEAREST: SEPTIC TANK ?-f--,SEWER' LINES Q7-PIT PRIVY �- <br /> SEWAGE DISPOSAL FIELD '. .CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LTNE�RIVATE DONEWEL�� U$LIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL s."", CONSTRUCTION SPECIFICATION <br /> Industrial „..�. I.- S i eU <br /> Cable Tool Dia: :of Well Excavation f R, <br /> Domestic/private Drilled ,f4 Dia. ,of Well Casing'- <br /> Domestic/public Driven Gauge of Casing �` <br /> Irrigation Gravel Pack �' Depth -of 'Gr6tt <br /> Seal <br /> Cathodic Protection Rotary $ f f.�Type of Grout <br /> Disposal —��` Other �.� _O:ther Information <br /> Geophysical. Surface..-Seal Installed By: <br /> rte` r t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> •t:E <br /> PUMP REPLACEMENT: <br /> /_7 State Work Done. , <br /> PUMP .REPAIR: <br /> /_7 State Work Done <br /> r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure `— <br /> • 4 <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 ofFmy. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL INSPECTION: ' <br /> SIGNED E TITLE �- <br /> P . P RE ERSE SIDE} <br /> FOR DE TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY,,. . DATE S <br /> ADDITIONAL COMMENTS: <br /> p��"•.� �/ , <br /> PHASE II-GROUT INSPECTIO PHAS I I/FI AL INSPECTTO <br /> INSPECTION-BY - DATE `IN.SPE ION. BY ,.DATE <br /> E H 1426 Rev: 1-74 , �� 3/76 2M <br />