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SAN JOAQUIN LOCAL`jHEALTH DISTRICT a' <br /> FO OFFICE USE: � 1601 E. Hazel ton,Ave- , .Stockton, Calif. <br /> ~ <br /> Telephone:a-,1(269 ' <br /> ,}(209) 466-6781 <br />' APPLICATION FOR WELL CONSI'ATICTION OR PUMP PERMIT Permit No. Z <br /> THIS,PERMIT;.EXPIRES 1 YEARo FROM r,DATEISSUED. ,' - - ,:Date Issued.� -7� <br /> ° sd;i '.: ai, 3 ,(Complete In-Triplicate)i 4a.s.:rr r. ,.. s t,. .. 9:;a <br /> Appliceitian is hereby made to the San Joaquiu,,Local_Health -District'' for ,,a,.permit to-construct <br /> and/or install the work herein described. ,.This a ' <br /> ,� . . _. pplication •is rtacie in compliance with- San Joaquin <br /> Countq'`Ordinance No ,1862;and the Rules arid- .Regulations;of:;the;,.Sam Joaquin Local'Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS i TRAC <br /> Owner S Name Phone '` <br /> Address ��'. _ ...... ; ..._ . <br /> "City i <br /> s <br /> Contractor's Name ` ' License.;U.. Phone r i <br /> TYPE OF.WORK (Check): NEW WELL /_19"DEEPEN' / RECANDITTON' /? ; DESTRUCTION /7 <br /> r PUMP :INSTALLATION, / PUMP REPAIR /-7 . PUMP REPLACEMENT <br /> r Other J� _ <br /> DISTANCE TO NEAREST; ;SEPTIC TANK : SEWER LINES :/ PIT PRIVY <br /> 1 s <br /> SEWAGE DISPOSAL FIELD? CESSPOOL:/.SEEPAGE PTT OTHER <br /> !PROPERTY .LINE w PRIVATE DOMESTIC -WELL PUBLIC�DOMESTIC WELL pa <br /> INTENDED USE :TYPE OF WELL !CONSTRUCTION. SPECIFICATIONS <br /> Industrial le Tool Dia,of Well Excavation. <br /> 'domestic/private Drilled Dia, of Well Casing <br /> Domestic/public: Driven i Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal- <br /> Cathodic ProtecCion Rotary, Type of Grout" ' <br /> Other <br /> Other Information � <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> x Type 'of Pump <br /> H.P. <br /> a r <br /> PUMP REPLACEMENT: L/ ;State Work Done <br /> PUMP :REPAIR: /7 .State- Work Done $ <br /> ESTRUCTxON OF WELL: Well Diameter 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''cons•trnctioh. ' Within FIFTEEN DAYS € <br /> after completion of : 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 im use.. The above <br /> information is true to- theebest.of`my.knowledge' and belief. I WIL'L' CALL` FOR:A GROUT .INSPECTION <br /> PRIOR TO GROU N AND A FININSPECTION. . � f <br /> SIGNED = 4 TITLE ,. .. <br /> DRAW FLOT PLAN ON REVERSE:SID <br /> ; . FOR .DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DACE <br /> ADDITIONAL COMMENTS: <br /> 'PHASE .II ;GROUT INSPECTIO N <br /> PHASE III FINAL INSPECTION_. <br /> INSPECTION BY DATE �7S� INSPECTION. BY" DATE <br /> 4 . E H 1426 Rev. 1-74 <br /> 1-74 2M <br />