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SAN JOAQUIN LOCAL HEALTH DISTRICT \A. <br /> - <br /> FOI4(OFFICE USE: 1601 E. Hazelton Ave. Stockton, C 4e-. N. <br /> Telephone: (209) 466-6 U �L�1�� I <br /> APPLICATION FOR WELL CONSTRUCTION,� iU� PERMIT it No. _ 3 7 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE %�S�� Issued <br /> (Complete In Triplic ) '\I\ � I <br /> Application ie hereby made to the Sat: Joaquin Local Healt S--" a a permit to construct <br /> and/or install the work herein described. This app�licatio�,id� in compliance with San JoaquinCounty Ordinance No. 862 and the Rules d Re u ati of. a San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ', ^j CENSUS TRACT <br /> VNyu AL1.4fl' le <br /> Owner's Name ` Phone <br /> Address a ° . City <br /> Contractor's Name , �U j ,. License # Phone ?®i i <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN17 RECONDITION /7 DESTRUCTION f7ALW <br /> PUMP INSTLATION / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST.:, SEPTIC •TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Q ' <br /> PROPERTY-LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED-USE TYPE OF WELL i 7CONSTRUCTION SPECIFICATIONS <br /> Industrial 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 o€. Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other_-_ Other-Information <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION.- Contractor... , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: jE/ State Work Done <br /> PUMP 99PAIR <br /> / State tidork Done" <br /> _ - —-. <br /> PE, S;TRUCTION OF WELL: Well Diameter Y 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 FO 'A GROUT INSPECTION <br /> PRIOR TO GRO . ING AND`` FIM INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE i <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT MSPECTION PHASE II FIX&L INSPECTIgN <br /> INSPECTION BY A, 4 DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-7A 9M <br />