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FOH1OFFICE USE: JOAQUIN LOCAL HEALTH DISTRIC-e,") J. <br /> , � 16b� E. Hazelton Ave, <br /> Telephone: Stockton, Calif. <br /> APPLICATION FOR WELL CONSTRUCTION 6OR1PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Comp ete <br /> Application is hereby made to the Sanoauin Local Health District fora permit to <br /> co <br /> and/or install the work herein described. This application is made in compliance withnstruct <br /> Joa uir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a7 D O <br /> Owner's Name CENSUS TRACT <br /> f g <br /> Address () Phone <br /> - <br /> City <br /> Contractor's Name <br /> W License # Phone <br /> TYPE OF WORK (Check): NEW WELL/7 :DEEPEN /7 RECONDITION /�� DESTRUCTION <br /> Other Z77 ,.,. <br /> PUMP INSTALLATION PUMP REPAIR 1-7—pump REPLACEMENT <br /> DISTANCE TO NEAREST; SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL U <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private (Cable Tool Dia. of Well Excavation <br /> Domestic Drilled Dia. of Well Casing <br /> /public __�driven Gauge of Casing <br /> Irrigati'gn Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Geophysical Other Other Information <br /> --------- <br /> �... Surface Seal Installe ". 15 <br /> PUMP INSTALLATION: Contracts-1 $ \ <br /> C <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done; ° <br /> PUMP :REPAIR: f <br /> /-7 State Work Don G <br /> S-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure 079 Approximate Depth ---�� <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Cdlifornia 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..Information is true to the best of my knowledge and belief. The above <br /> °RIOR TO GROUTING AND A FINAL INSPECTION. I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APP A ION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY P I FINAL INSPECT -m-7- <br /> DATE / INSPECTION BY <br /> vD TE <br /> �' <br /> E H 1426 Rev. 1-74 {t� <br />