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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> SOF OFFICE US : <br /> .11601. E. Hazelton Ave. , Stockton, Calif. <br /> 3 <br /> Telephone: (209) '466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> k Date Issued <br /> I <br /> Application is In Triplicate) - <br /> hereby made to the San (J Joaquin eLocal 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 /> f County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> < CENSUS TRACT f <br /> Owner's Name _/J <br /> Phone . ��' <br /> Address <br /> City lc <br /> Contractor's Name <br /> License # Phone ` <br /> TYPE OF WORK (Check) NEW' WELL1 <br /> DEEPEN/ / RECONDITION DESTRUCTION /-7 <br /> PUMP INS AL ATION <br /> / / PUMP REPAIR / / PUMP REPLA.OtherCEMENT /7 <br /> f <br /> .U-! ------------ <br /> PTANCE TO NEAREST: SEPTIC, TANK <br /> SEWER LINESZo _6g2_+ PIT PRIVY <br /> : SEWAGE-DISPOS FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINEV�! OTHER <br /> INTENDED USE PRIVATE DOMESTIC WELL " PUBLIC DOMESTIC WELL <br /> TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> _ Cable Tool Dia, of Well Excavation j <br /> Domestic 'j <br /> /private Drilled Dia, of Well Casing <br /> Domestic/pub;ic-�"'"' a of Casing <br /> i u <br /> Driven Gauge g g <br /> n Gravel Pack Depth of Grout Seal l f <br /> Cathodic Protection Rotary Type of Grout <br /> iDisposal <br /> Other _ Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P, <br /> PUMP REPLACEMENT: / / State Work Done, ' <br /> PUMP :REPAIR: / / State Work Done <br />)ES-T'RUCTION OF WELL: Well Diameter <br /> Describe Material andwProcedure Approximate Depth <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> ifter 'completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br />.nformation is true o the s of � n dge and belief. I WILL CALL FOR A GROUT INSPECTION r <br /> RIOR TO G A FI S I <br />',IGNED" 1 <br /> TITLE tit 1 <br /> (D PLOT PLAN ON REVERSE SIDE) 1 <br /> RASE z <br /> OR DEPARTMENT USE ONLY j <br /> PPLICATION ACCEPTED BY G <br /> DDITIONAL COMMENTS: r DATE , <br /> P I CTI PHASE III/FINAL INSPECTION ' <br /> NSPECTION BY DA INSPECTION BY DATE <br /> `7 ^� <br /> E H 1426 Rev. 1-74 1�f i d <br />