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SAN JOAQUIN FOCAL HEALTH DISTRICT <br /> ay ��`Jti <br /> FOK", ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T -3002 <br /> THIS PgRMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued R-7 <br /> A (Complete In Triplicate) <br /> 'plication is hereby made to the San Joaquin Local kIealth District for a permit to construct <br /> and/or instar. 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 /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City �`- <br /> Contractor's Nai>t � cense <br /> Phone <br /> TYPE OF WORK (Check): NEW WELL -7 DEEPEN/? RECONDITION /? DESTRUCTION f7- <br /> PUMP INSTALLATION / PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other /% -- <br /> 4 w t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> .f � y _ SEWAGE DISPOSAL FIELD <br /> PROPERTY OTHER <br /> LINE '- PRIVATE DOMESTICSWEOGE <br /> L/SEEPAPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � � Cable Tool. Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven f <br /> "`Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> ! Disposal ; Other Other Information + <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor <br /> Type o£'Pump rte, kA.H.P. ` <br /> PUMP REPLACEMENT: State Work Done Al <br /> PUMP :REPAIR: 7 State Work Doane <br /> E.&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 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 <br /> information is true to the-best•of. m .know a and b lief'. I WILL CALL FOR A GROUT INSPECTION <br /> g- the- well in use. The above <br /> PRIOR TO G AND FINAL IO . <br /> SIGNED °1 � <br /> ZTLE <br /> OT ON RE RSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY y� a. <br /> ADDITIONAL COMMENTS: DATE J <br /> PHASE IT GROUT INSPECTION PHASE TI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE y <br /> r <br /> > E H 1426 Rev. 1-74 i � � <br />