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CJ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (200) 466-6781 ! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . 6 <br /> (Complete In Triplicate) <br /> Apnlicati"on Is hereby made to the San Joaquin Local Health Diatrict -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 /> r '� � �- ` ENSUS TRACT <br /> K <br /> u , <br /> Owner's Name ' / <br /> Phone ' <br /> Address " <� <br /> City <br /> Contractor's Name License #/G)_373 Phone <br /> 3-c d 1 � <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /? RECONDITION /_7 DESTRUCTION j f - <br /> PUMP INSTALLATION PUMP REPAIR 1_7 PUMP REPLACEMENT <br /> Other Ll --- <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ),.:'CONSTRUCTION SPECIFICATIONS 6' } <br /> Indus trial_ _ —.— Cable Tool—...,-Dia.:-o£--We3-1 Excavation*-'-- <br /> ? Domestic/private Drilled Dia. of Vell Casing <br /> Domestic/public Driven. Gauge of Casing 3 - <br /> �� __ , . <br /> Irrigation : li �t� Graver Pack Depth of Grout Seal <br /> Cathodic Protec�'ion'! Rotary Type of Grout <br /> Disposal ;'� Other Other Information ' ' <br /> Geophysical Surface Seal Installed By <br /> _ qtr <br /> 1 <br /> PUINSTALLATION: contractor <br /> tractor <br /> Type .of Pump <br /> H.P. <br /> r <br /> PUMP REPLACEMENT: . �� State Work Done <br /> PT2 .REPAIR: +/1/. State -Work Done T <br />)ESTRUCTION OF WELL: 'Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> Z hereby agree.to complylwith all laws and regulations of the SanJoaquin 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 /> TELL DRILLERS REPORT of the well and notify them-before <br /> Y putting.. the..well. in{{.use.... .The above <br /> Lnfotmatio i true to th -best-of- my.-knowledge and belief. I WILL CALL FOR A GROUT- INSPECTION{ <br />'RIOR TO G IN AND NAL INSPE TON. <br /> SIGNED ` TITLE <br /> IZAD PLOT PLAN ON,"REVERSE SIDE : <br />?RASE I DEPARZ <br /> MEN�j T USE ONLY <br /> 'PLICATION ACCEP fJE�C-x L.� DATE ' '�� ' 7 <br /> WDITIONAL COMMENTS: ;I <br /> PHASE II GROUT INSPECTION PHASE III F AL INSPECTION <br /> LNSPECTION BY _ ,/ DATE z-a `�1 INSPECTION BY DATE. f� <br /> E <br /> H1426 Rev. 1-74 h/75 2M -.._ <br />