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TTS <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOCOFFICE USE• 1601 E. Hazelton Ave. , Stockton, Calif. y <br /> Telephone: (209) 466-6781 7� ��/� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./ 1 F <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 construe] <br /> and/or install the work_..herein d <br /> escribed. This application is made in compliance with San Joaquin <br /> County' Ordinance No. 1862 and the Rules and R ulations of the San Joaquin Local Health District. <br /> CENSUS TRACT' <br /> JOB ADDRESS/LOCATION ` <br /> �. Phone <br /> Owner's Name <br /> f ' ' City <br /> Address / <br /> License Phone 46c3a/ pp <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION /�/ DESTRUCTION /7 . <br /> PUMP INSTALLATION I I PUMP REPAIR / I PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LPIT PRIVY <br /> FIELD '�O CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FI /J <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE-.,. , TYPE OF WELL 1 <br /> ?ndus trial :,' <br /> Cable Tool Dia. of Well Excavation J� <br /> Domestic/private_ Drilled Dia. of Well Casing <br /> f _ Driven Gauge of Casing _ 0, <br /> Wit. Domestic/public - <br /> Gravel Pa k � 'tn.�.f�Grout=5ea1 .�Sl�_- <br /> h irrigatiion <br /> Cathodic Protection GrRotary Type of Grout <br /> llisposal ., Other Other Information <br /> Geophysical -- _ Surface Seal Installed__By I <br /> pUMP,INSTALLATION: "Contractor <br /> �-' Type of Pump �.�'.. :., H.P. <br /> PUMP REPLACEMENT: j/ / State Work Done <br /> PUMP .REPAIR: / State Work-.Done <br /> - DES•TRUCTION OF WELL: Well.Diameter Approximate Depth _ <br /> ,: Describe Material and Procedure <br /> agree to comply with alb 1 1 s and regulations of the San Joaquin Local Health District <br /> I hereby agr p y <br /> aria the State of California pertaining to or regulating well"construction. Within FIFTEEN DAX <br /> ork onL.new well, I will furnish the San Joaquin Local Health District a <br /> after completion of my f <br /> WELL;.DRILLERS REPORT- of -the-well and notifyithem,,before putting the well in use. The above <br /> :., <br /> information is true to the best of my knowledge', aiid' belief --, <br /> I-"WILL CALL FOR A GROUT INSPECTION <br /> 4 PRIOR 'TO G -AUD A 'FI3ALZINSPECTION. <br /> SIGNED TITLE <br /> t DRAW PLAN ON REVERSE SIDE `kl <br /> FOR DEPARTMENT USE ONLY �. <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> 5 <br /> *DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III'/F NA INSPECTI N <br /> r INSPECTION BY <br /> DATE INSPECTION BY DATE <br /> ' 3/76 2Ni <br /> G E H 1426 Rev. 1-74 # <br />