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y <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: it/w 1.601 E. Hazelton Ave. , Stockton, Calif. 01 <br /> Telephone: (209) 466-67814 WA <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITrormit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <br /> Application is hereby made to the San <br /> (Complete <br /> LocalTriplicate) <br /> Dis.trict fora pe it <br /> and/or install the work herein described. ct <br /> This application is made in compliance twith nSan uJoaquin <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 /> Contractor's Name f <br /> License one <br /> TYPE OF WORK (Check) : NEW WELL IX-7 DEEPEN / / RECONDITION/ // DESTRUCTION /`7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 16 Q <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracto P,4 dkl S. - Ire/ & <br /> Type of Pu H.P. "5-- <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR; State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true jtp the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GIPUT94G .. A INAL INSPE ON. <br /> SIGNED Mf TITLE <br /> RAW PLIDT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 109 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ,�/ P SE /FIN INSPECTION <br /> INSPECTION BY DATE / INSPECTION BY DATE 7 <br /> /77 <br /> E H 1426 Rev. 1-74 376 2M <br />