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41 SAN JOAQUIN LOCAL HEAL'�"1 DISTRICT <br /> FOF�;OFFICE USE: 1641 E.' Hazelton Ave. , Stockton_, Calif. <br /> Telephone: (209) 466-6781 _,-. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 � <br /> 'I -L---` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED <br /> Date Issued p...LL <br /> (Complete In Triplicate). <br /> Application is hereby made to the Son 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 an the Rules and Regulations of the Sam Joaquin Local Health District. ' <br /> 3� i <br /> JOB ADDRESS/LOCATION , { ` <br /> r CENSUS TRACT <br /> Owner's Name ( . <br /> Phone <br /> Address <br /> City - <br /> Contractor's Name <br /> License � <br /> r e <br /> TYPE'OF WORK (Check) : NEW WELL -/} -DEEPEN -/-7 RECONDITION %f DESTRUCTION /_' <br /> PUMP INSTALLATION PUMP REPAIR -7PUMP REPLACEMENT /7 <br /> Other -- <br /> DISTANCE TO NEAREST: T <br /> SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL f' <br /> € TYPE OF WELL <br />— Indust— r�� CONSTRUCTION SPECIFICATIONS <br /> Tool F� Cable Too <br /> Domestic/private " q Dia. of Well Excavation t <br /> t Trilled Dia. of Well Casing •% <br />_ Domestic/public <br /> -Driven `.Gauge of Casing <br /> Irrigations Gravel Pack• Depth of Grout, Seal <br /> Cathodic Protection::� Rotary Type of Grout ' r <br /> Disposal t Other <br /> Geophysical Other Info' t. <br /> - Surface Seal, Installed `B <br /> PUMP INSTALLATION: ------ — -= <br /> Contractor <br /> Type of Pump d 4 <br /> H.P.. <br /> PUMP j <br /> REPLACEMENT: <br /> State Work Done <br /> PUMP_'.REPAI - _t -_ <br /> • Work Done t k : :� .•- . .•- _ 6 <br />)ES TRUCTI � ` �' `'�• <br /> QN _OF WELL.: -Well Diameter �_ �., <br /> Describe Material and Procedure ""�Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District i <br /> Ind the State of California 'pertaining to or° regulating well •construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I :wiil furnish the San Joaquin Local Health District a <br /> FELL DRILLERS REPORT of the ;well and notify �"them before putting.the..well. inuse-. . .The above <br /> nformation is true to the•best-of- my..knowledge and belief. I WILL CALL -FOR 'A 'GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE <br /> DRAWPLOTPLAN ON REVERSE SIDE <br /> RASE I FOR DEPARTMENT USE ONLY . <br /> PPLICATION ACCEPTED BY. a <br /> DDITIONAL COMMENTS: t . I DATE <br /> PHASE II GROUT .INSPECTION PHA I <br /> NSPECTION BY DATE INSPECTION BY INSTEPECTION <br /> E H 1426 Rev. 1_74 <br /> �r ,_ <br />