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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi7OFF�ICE USE: 1601 E. .Hazelton Ave. - Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;:g5- <br /> THIS <br /> ,6_THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S <br /> CENSUS TRACT <br /> Owner's Nance <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> icense # 4 Phone.-'2 Z <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN -/_7 RECONDITION /'7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION L-7 PUMP REPAIR L-7 PUMP REPLACEMENT <br /> Other -� <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY J <br /> SEWAGE DISPOSAL'IF ELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> PROPERTY LINE - PRIVATE IIOMESTIC WELL PUBLIC DOMESTIC WELL�� <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> _ , Cable Tool. Dia. of Well Excavation <br /> Domestic/private Drilled Dia". of 4Fe11 Casing <br /> /public Driven � . <br /> Irrigation Gauge of. Casing <br /> Gavel Pack Depth of Grout Seal <br /> Cathodic Protection /Rotary Type of Grout <br /> Disposal - ' Other Other Information <br /> Geophysical -�----�--- <br /> 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•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate -Depth <br />= hereby agree to comply with all laws and regulations of the an Joaquin LocWl Health District <br /> cnd 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 <br /> FELL DRILLERS REPORT of the well and notify them before putting the..well in use.... The above <br />.reformation is true to the,best -of my..knowledge and belief. I WILL CALL FOR A <br /> RIOR TO G OUTIN AN FINAL NS CTI <br /> GROUT INSPECTION <br /> IGNED f Y <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> HASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: /y DATE Av7�aA <br /> PHASE IT GROUT INSPECTION `A— <br /> LISPECTION BY PHASE III FINAL INSPECTION <br /> DATE ,� _ INSPECTION BY DATE „x <br /> E'H 1426 �. <br /> _Rev. 1-74 _.. -- r- c. �•sr .,,,R <br />