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SAN J'OAQUIN LOCALHEALTH DISTRICT <br /> E OFFICE USE: 1607 , Hazelton Ave. , .Stockton, Cala <br /> Telephone: (204)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No27_11A— 1'' <br /> � THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;. <br /> (Complete In Triplicate) <br /> lication is Hereby made to the San Joaquin Local Health District for a permit to construct <br /> /or install the work herein described. This application is made in compliance with San -Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F3 ADDRESS/LOCATION <br /> I�I� ;Z <br /> 7� CENSUS TRACT <br /> wner's Name <br /> Phone <br /> Firess <br /> City <br /> tractor's Name License Phnne _ - i <br /> IE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_� DESTRUCTION /_7t PUMP INSTALLATION PUMP REPAIR/ / PUMP RFPLACEMENT /? <br /> Other <br /> F3TANCE TO NEAREST: SEPTIC.TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> t <br /> Ft_ Irrigation Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> F;-- <br /> Geophysical Surface Seal Installed By: <br /> UIT INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: / / State Work Done <br /> FT_REPAIR: / / State Work Done <br /> ..TRUCTION OF WELL: Well Diameter � �-, _ Approximate Depth <br /> Describe Material otnd Procedure <br /> ereby agree to comply with all laws and' regulations of the San Joaquin Local Health District <br /> i the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> icer completion of my work on a new well, I will furnish the San Joaquin Local Health District_ a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ormation is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> r <br /> TO G G�ANDAINAL S <br /> TITLE <br /> ( RAW PLOT PLAN ON REVERSE SIDE)' <br /> FOR DEPARTMENT USE ONLY ~ <br /> RASE I <br /> LIGATION ACCEPTED BY `rte E � / <br /> 3ITIONAL COMMENTS: --7 <br /> DAT .7- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> PECTION BY DATE INSPECTION BY DATE s ' <br /> E H 1426 Rev. 1-74 /I/ - 2M <br />