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_., SAN JOAQUIN LOCAL HEALTH DISTRICT G, <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. (L / <br /> Telephone : , '(209) 466-6781 ��''s-.3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - Date Issued <br /> (Complete .In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or: install the work heresn described..• .This application is made .in compliance with San Joaquin <br /> County Ordinance No. 1862 an'd the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Name - U/Aev Phone <br /> Address - , <br /> City I <br /> Contractorfs Name A 11 License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN Y/ RECONDITION / / DESTRUCTION /-7 - <br /> PUMP INSTALLATION UMP REPAIR / / PUMP. REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC, TANK r SEWER LINES PIT PRIVY <br /> SEWAGE';DISPO. AS L FIELD- CESS OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,fip r;,., i.� ''k CONSTRUCTION SPECIFICATIONS T _ 1 <br /> Industrial It,--Cable Tool - Dia: of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public ! DrivenGauge of Casing <br /> Irrigation GravelPack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout A¢6 tV-,� <br /> Disposal ! Other Other Information 9 <br /> -14 Geophysical '" Surface Seal Installed BY: <br /> 5 <br /> PUMP INSTALLATION: Contractor <br /> ..-'TY-pe of Pump.. H.P. <br /> � <br /> 1 <br /> PUMP REPLACEMENT: / State Work Done - f ' <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describ"e Material and Procedure <br /> I hereby agree to comply with} all Jaws and regulations of the San Joaquin Focal 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 thewell in use. The above <br /> information is t ue to the b s f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TI A FIN PECTIUN, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> # FOR DEPARTMENT USE ONLY # <br /> P SE I <br /> APPLICATION ACCEPTED. BY DATE Z <br /> ADDITIONAL COMMENTS:- <br /> PHASE <br /> OMMENTS:-PHASE II .GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY 'r A' A -E E 7 "7 <br /> F <br /> E H. 1426 ' Rev. '. -74 '^..__ K 0/%7 _ 2M <br /> . ,{j <br />