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I/ SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> F',OF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:' (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.- - <br /> 14)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 herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No: 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .,,JOB ADDRESS/LOCATION <br /> I I CENSUS TRACT <br /> ti O.Wner's Name , <br /> Phone <br /> Address 70 <br /> City .�.T <br /> J. Contractor's Name License �� QPhone G;Pcj] <br /> .,. <br /> 4 1 <br /> ti TYPE OF WORK (Check) : NEW WELLV --�DEEPEN-r,/% RECONDITION DESTRUCTION /7 <br /> k° PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other/f/-- <br /> r <br />`r'BISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing • <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Informations <br /> C . Geophysical Surface Seal Installed. B : <br /> UMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br />'PUMP REPIGEMENT a ,',.5tate Work Done <br /> PUMP REPAIR:•. tate Work DoneAt <br /> = <br /> s�.. . . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ! <br /> �. ...,,,....Des cr.ihe-Mate r.ial_and_.P_rocedur.e._. <br /> 1 :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 "'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 the well in use. The above <br />,'information is true to the best:of my knowledge and belief, I WILL CALL F R A GROUT INSPECTION <br /> PRIOR TO GROING AND FINAL INSPECTION. <br />•SIGNED 7 ;" TITLE <br />-_-` =...sem (DRAW PIAT ,PLAN ,ON .REVERSE,SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY°; <br /> APPLICATION ACCEPTED BY.- DATE �. <br />'AADITIONAL COMMENTS: <br /> PHASE II UT INSPE9TION P I/ INSPECTI N <br /> INSPECTION BY DAT INSPECTION B r DATLO <br /> -E H 1426 Rev- 1-711 t A77„ ^:ons' <br />