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y FOF SAN JOAQUIN LOCAL HEALTH DISTRICT .�� <br /> OFFICE USE; ` 1601 E. Hazeltori-Ave. , Stockton, Calif. I g �� <br /> � tTelephone : (209) ,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued y-r3 <br /> f t ----(Complete In Triplicate) _ <br /> Application is hereby trade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. Th s.fapplication is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules- and Regulations of the San Joaquin Local He <br /> alth District. <br /> JOB ADDRESS/LOCATION _S R S OF J , j <br /> CENSUS TRACT <br />! Owner's Name ' <br /> Phone <br /> Address , S.3 1 <br /> ' <br /> City <br /> Contractor's Name License #lj6 f�}7,� Phone f�a� <br /> TYP E OF WORK ".` _ <br /> (Check) ; NEW WELL / DEEPEN !/ /RECONDITION DESTRUCTION /_7 -� <br /> PUMP INSTALLATION / / PUMP REPAIR /K/ PUMP REPLACEMENT <br /> Other `/�� <br /> DISTANCE TQ NEAREST: SEPTIC TANK <br /> f gyp- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �_ 'CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE XOPRIVATE DOMESTIC WELL _1nP PUBLIC DOMESTIC WELT, � + <br /> .INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFTCATTONS <br /> Cable Toa! Dia. of Well Excavation <br /> k Domestic/private;"`• Drilled Dia. of Well Casing <br /> Domestic '► <br /> /public Driven Gauge of Casing / a„ F <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protectioin i Rotary e of Grout <br /> Disposal I Other Type <br /> �to go <br /> � - <br /> Geophysical Other Information <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-rREPAIR-• � /-:/ -S tate=WorkDonQ ; <br /> DESTRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth f <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 -construction. Within FIFTEEN DAYS <br /> after comple.tio work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLE REPORT f thew 1 and fy them before putting the -well in use. The above <br /> inform is true th <br />?RIOR TOO G OUT G A N b o ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> G <br /> SIGNED TITLE <br /> DRAW PL T' PLAN ON REVERSE SIRE} <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS: DATE ".Z.2_ <br /> 1 <br /> PHASE II GROUT INSPECTION PHASE III FIINSPECTION. ' -4 <br /> INSPECTION BY' DATE �J INSPECTION BY <br /> I � % DATE � :# <br /> E H -1426 Rev. 1-74 <br /> iz, 3/76 2M A <br />