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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi'lZEFICE USE; � il '.% <br /> 601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued, <br /> Applicati (Complete In Triplicate) <br /> on is hereb _ <br /> y made to the San Joaquin Local health District for a permit to construct <br /> i and/or install the work herein described. This application is made.ln compliance with San Joa u' <br />' County Ordinance No. 1862 end the Rules and Regulations of the San Joaquin Local Health District,.q is <br /> JOB ADDRESS/LOCATION <br /> CENSUS.TRACT <br /> Owner's Name , g�� <br /> Address <br /> Phoneme <br /> J,� .' � �._ � <br /> City ' L8C 8,4 01v <br /> Contractor's. Name ' <br /> License # 0i(D Phone <br /> TYPE OF WORK (Check): NEW WELL I? DEEPEN/7 RECONDITION - <br /> . PUMP INSTALLATION n��'T DESTRUCTION f7 <br /> Other '/% / Pte' REPAIR .j` .PUMP REPLACEMENT /7 <br /> DISTANCE TON ST: SEPTIC TANK f <br /> SEWAGE DISPOSAL FIELDER LINES PIT PRIVY � <br /> CESSPOOL/SEEPAGE PIT - _ OTHER <br /> 7 PROPERTY LINE -- PRIpATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION5 <br /> Industria]. � • Cable Tool Dia. °of Weil Excavation � <br /> ,�- Domestic/private Drilled Dia. o£'Well Casing 1 <br /> Domestic/public Driven.. <br /> Irrigation '^:-�"" Gauge of Casing <br /> Gravel-,Pack Depth -of Grout Seal <br /> . Cathodic Protection t � Rotar <br /> Disposal - ,....._ ,- 3' _._ � Type of Grout � <br /> Other Information '-,' <br /> Geophysical Oth <br /> � _ --------;�--•-• -- � .� <br /> L Surface Seal InstalLed 'By: . <br /> PUMP INSTALLATION: <br /> Contractor k i <br /> Type .of Pump <br /> _ r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-'REPAI_:_R:_. �' <br /> !:�' � State Work Done <br /> . t � <br /> �� <br /> DESTRUCTION OF WELL: n :Weil-Diameter <br /> ' `eXs Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with-all laws and regulations of the San Joaquin- Local Health-FIS.-trict . <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' I <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 /> tiRIOR TO GR UT G D IN INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE 'SIDE <br /> PI q FOR.DEPARTMENT USE ONLY <br />�WLICATION' ACCEPTED BY MIA <br /> LDDITTONAL COMMENTS: DATE : . - <br /> PRASE II GROUT. INSPECTION P I AL INSPECTIO <br />:NSPECTION BY DATE <br /> INSPECTION B DATE . <br /> E'H'1426 Rev. 1-74 7f <br />