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- � SAN JOAQUIN LO8ALL HEALTH DISTRICT <br /> FOFir0FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 an a natio f he San oa uin ocal ealth District, <br /> eLl <br /> JOB .ADDRESS/LOCATION f �' US TRACT <br /> Owner r s Name Phone <br /> I <br /> Address Citi I <br /> i <br /> Contractor's Name License # Phone <br /> s <br /> - t <br />. .TYPE OFrWORK (Check) .—NEW WELL-/ . —DEEPEN--/7-�-RECONDITION-/77- DESTRUCTION ^/7 " <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 7pump REPLACEMENT 17 <br /> s Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY • <br /> i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER {,� # <br /> PROPERTY LINE �- PRIVATE DOMESTIC -WELL-:" -PUBLIC'DOMESTIC'"WEI:i ~y ? <br /> INTENDED USE -- TYPE OF WELL . , CONSTRUCTION-SPECIFICATIONS. <br /> 'Industrial <br /> _ s <br /> Industrial b- Cable Tool Dia. -of Well Excavation <br /> r Domestic/private Drilled 4 Dia. 'of�Well Casing <br /> - - <br /> Domestic/public Driven Gauge of Casing 10 OAX, f L/A <br /> - r-- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary y `}. , Type of Grout <br /> Disposal Other Other Information. . <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -- - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'.REPAIR: J-7 State Work Dane ` F <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 Distri.CK <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 /> WELL DRILLERS REPORT of the well and notify them before putting the- well in use.. The above <br /> information is true to the-best o€- my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION.` <br /> SIGNED P144494,42TITLE <br /> (DRAW PLOT`PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION P II NAZ INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br />'I �� 'E S 1426 Rev. 1-74 1-74 2M <br />