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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F£►F� OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> f j Telephone: • (209) 466-6781 <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)and/or <br /> ins Application is-hereby hework <br /> meds 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 Joagtilp <br /> County'Ordinance No. 1862 and the Rules and Regulations of the San 'Joaquin Local Health District., <br /> 4 <br /> JOB ADDRESS/LOCATION <br /> -- CENSUS TRACT 2-01- 2--Y0 7 <br /> Owner's Name <br /> Phone , <br /> Address <br /> City . . <br /> Contractor's Name <br /> License ! ' Phone - <br /> TYPE OF WORK (Check,) : NEW .WELL /? DEEPEN /? RECONDITION /77. <br /> PUMP INSTALLATION ./ / PUMP REPAIR '/? PUMPEREPLACIEMEN-T /`j <br /> ON f7 <br /> 01 <br /> / <br /> Y< kt Other <br /> I� <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES • FIT PRIVY <br /> SEWAGE DISPOSAL PIELD CESSPOOL/SEEPAGE_PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL::.. ..... PUBLIC DOMESTIC OTHER <br /> O <br /> INTENDED USE TYPE OF WELL -CGr <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation S <br /> Domestic/private Drilled C <br /> Domestic/public - Dia. of Well Casing' � - <br /> Driven Gauge of Casing J. <br /> Irrigation Gravel Pack Depth of Grout' Seal ter # <br /> Cathodic Protection Rotary Type of Grout i` n <br /> GGeopphhysysiical Other Other Information <br /> eo --"�------- <br /> Surface Seal Installed B <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump F <br /> H.P. <br /> PUMP REPLACEMENT: . f/ State Work Done - ' <br /> PUMP 'REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe. Materialand Procedure Approximate Depth r <br /> -- <br /> I hereby agrees to comp. <br /> I <br /> arid the State of Californiapertainingtodoreregulating wellgulations of "'construction.San Joaquin LoWithin cal aFIFTEEN <br /> lth trict <br /> DAYS! F <br /> after completion of my work. on a new well, I will furnish the San Joaquin Local Health Districts N <br /> WELL DRILLERS REPORT of the well and notify them before putting.. the..well. in.usg.... :The above � �� <br /> information is true to tte•best of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION'' <br /> PRIOR TO GROUT G ' D NAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLAT PLAN ON REVERSE SIDE <br /> FOREPARTMENT USE ONLY <br /> HASEw,L - ` <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS DATE <br /> PHASE II GROUT I PECTION' <br /> INSPECTION ByPH&aI INAL INSPECT N <br /> - DATE ,1 INSPECTION By <br /> DATE <br /> P. <br /> E H 1426 <br /> Rev. 1-74. �,. �. . �� f.��� .�r•-r ,.! <br />