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+N JOAQUIN LOCAL HEALTH DISTRICT _ <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 'i 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 tct 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 Jo ' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION •� <br /> CA* CENSUS TRACT <br /> Owner's Name �,.�D� • �� •' <br /> � .Phone -- <br /> Address 2Agione City <br />' Contractor's Name j License #J2b_S 7 6/ Phone � <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN '/ / RECONDITION /? yDESTRUCTION /_7 ~ <br /> PUMP INSTALLATION / — PUMP REPAIR / / PUMP REpLACIM% /7 <br /> Other E7 <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK _10? '• SEWER LINES --PIT_PRIVY 1,r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- , OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIGGWELL PUBLICiY0RiSTIC WELL <br /> INTENDED USE TYPE OF WELL' CONSTRUCTION:SPECIFICATIONS <br /> Industrial. , <br /> Domestic .. ` 01 Dia. •of- Well Excavation <br /> /private Drilled Dia. of Well Casing f J t <br /> Domestic/public Driven Gauge of Casing <br /> on <br /> Gravel Pack Depth of Grout Seal '--:j <br /> E - Cathodid Protection Rotary Type of Grout <br />! Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed <br /> V <br />' PUMP INSTALLATI N: - :"Contractor <br /> Type of. Pump <br /> 1 H.P. 3 <br /> PUMP REPLACEMENT:, ; - .,,�}�,,;•y <br /> State Work Done <br /> PUMP -REPAIR: - <br /> / / State'-Work Done <br /> - r <br /> f DESTRUCTION OF WELL: Well' .Diameter <br />� .>- <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all .laws and regulations of the San Joaquin Local Health Districtf <br /> and the State of California pertaining to or regulating we <br /> construction. Within_FIVT EN 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 r <br />` information is true to the best of- my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> 'RIOR TO GROUTING AND A,FINAL INSPECTION. <br />; SIGNED . <br />€ <br /> TITLE ' <br /> (DRAW T PLAN ON REVERSE SIDE <br /> 'RASE I FAR DEPARTMENT USE ONLY <br /> 1PPLICATION ACCEPTED BY DA'Z'E <br /> WDITIONAL COMMENTS: <br /> PHASE,. II G PE TON PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY ,,I .• - DATE /.3r • .fi-7 <br />; <br /> Aoe - <br /> I �E H 1426 Rev. 1-74 1fx7 2M <br /> r <br /> E <br />