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F <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOF�;OFFICE USE: 1601 E. Hazelton A,re. , Stockton, Calif. <br /> it Telephone:, (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP PERMIT Permit No. <br /> _ -1�Y <br /> ,. p r <br /> THIS' PERMIT EXPIRES I YEAR FROM DATE -ISSUED.' <br /> .,� r� DateIssued ; <br /> Application is hereby made to the San�Joaquin Local Helete In alth D} � <br /> ; :. <br /> and/or`install the work herein described. istrict-. forFa permit to ,construct ' <br /> ' <br /> County Ordinance No. 1662 and -the Rules and Regulations.iofn is niacte to 'cemplian�e with San-Joaquin <br /> .1Ithe San Joaquin Local Health:D1etrict <br /> JOB ADDRESS/LOCATIONje <br /> ' ° <br /> M r CENSUS TRACT - <br /> Owner's Name 2 _ <br /> Address `Phone <br /> . , <br /> ° ! City <br /> ,Contractor'.s Name r <br /> ! License # hone <br /> ��. IDI_ <br /> 'TYPE OF WOitK (Check): NEW WELL 7 DEEPEN /_7 RECONDITION I-7 DESTRUCTION <br /> PUMA' INSTALLATION / / PUMP REPAIR <br /> EM <br /> Other /%. . .. /� PUMP REPLACENT <br />'DISTANCE; TO NEAREST: SEPTIC TANK <br /> SEWER LINES Idd PIT PRIVY ! <br /> f <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT-1 <br /> PROPERTY LINE -- PRIVATE DOMESTIC -WELL" PUBLIC DOMESTIC WELL I p <br /> INTENDED USE � TYPE OF WELL J <br /> In ustrial CONSTRUCTION SPECIFICATIONS <br /> „__.�,, Cable Tool Dia. of Well Excavation (^ <br /> Domestic/private Drilled <br /> Domestic/public Dia. of. Well Casing i <br /> Irrigation Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Dispersal , _ Other Other Information . i <br />^__,•,T Geophysical . <br /> .� Surface Seal Installed''B <br /> PUMP INS T - I <br /> ALLATION: Contractor <br /> Type of PumpR R. <br /> ji � <br /> PUMP REPLACEMENT StateWork Done <br /> PUMP 12EPAIR; /-7 State Work Done <br /> IE&I RUCTION OF WELL: Well Diameter- <br /> Approximate <br /> # <br /> Approximate Depth <br /> Describe!Material and Procedure y <br /> hereby agree to comply with all laws and regulationsyof the San Joaquin LocalHealth District , <br /> ind the State of California pertaining to or regulating well construction., Within FIFTEEN DAYS <br />!fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a.' II <br /> TELL, DRILLERS REPORT of the well and- notify them before Putting-the:-well in.use.... .The above I <br /> nformation is true to•the�-best-of- my.knowledge and belief. I WILL CALL -FOR.'A GROUT INSPE <br /> RIOR TO GROUTING `AND A FINAL INSPECTION.' CTION. <br /> IGNED <br /> .TITLE <br /> DRAW. PLOT PLAN ON REVERSE SIDE j <br /> RASE I yI FQR DEPARTMENT USE ONLY <br /> E'PL_ICATION ACCEPTED BY <br /> DDII ONAL..GflMMENTS: :;� DATE ' ' <br /> ,z 7 <br /> PHASE II GROUT INSPECTION <br />!ISP$CTION BY ij DATE P IIF AL INSPECTION <br /> --�-- _ INSPECTION BY DATE .- �--7 <br /> E ;H 1426 Rev. 1-74 I _ .- <br /> - L i7 a .,,. <br />