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FOE­O CE USE• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i <br /> Telephone: (209) 466-6781 :: <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, p <br /> I THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Date Issume l S <br /> (Complete In Triplicate) — 197 19�Z: <br /> Application is hereby made to the San 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 Joa uiri <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District; <br /> JOB ADDRESS/LOCATION 'Q Sri <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 31 --� <br /> City <br /> Contractor's Name <br /> License ,leu Phone <br /> TYPE OF WORK (Check); NEW WELL - i- <br /> DEEPEN /_/ RECONDITION T_7 DESTRUCTION /7 <br /> PUMP INSTAL TION / ./ PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other El <br /> DISTANCE TO NEAREST: SEPTIC TANK 422L SEWER LINES � � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL <br /> /SEEPAGE PIT OTHER <br /> PROPERTY LINE – PRIVATE DOMESTIC WELL � PU$LIC DOMESTIC WELL <br /> � <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well. Excavation / <br /> _ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public �• <br /> Irrigation Driven Gauge of Casing <br /> Gravel Pack Depth of Grout S a�l� <br /> Cathodic Protection Rotary <br /> Y Type of Grout - 3_9 a <br /> Other Other information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ;q H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter <br /> Describe. Material and Procedure Approximate Depth <br /> I .hereby agree to comply with all laws and regulations of the ;an Joaquin Local Health District > <br /> E <br /> and the State- of California pertaining to or regulating well'construction. Within FIFT �t DAYS: <br /> after completion of my work on a new well, I will furnish the SantJoaggin 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. <br />'RIOR GROUI WILL CALL FOR A GROUT INSPECTION <br /> TI AND FIN INSPECTION. <br /> SIGNED <br /> TITLE <br /> P ON ) <br /> SE S113E <br /> CHASE I <br /> FOR DEPARTMENT USE ONLY <br /> R <br /> iPPLICATION ACCEPTED BY <br /> 1DDITIONAL COMMENTS. DATE Q <br /> PHASE II OUT INSPECTION P E II •INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE -,_/—, _ <br /> E H 1426 Rev. 1.,74 <br /> 3/76 2M•• <br />