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FOR,OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. <br /> Stockton, Calif. <br /> 167, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7C- �oS3 W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��~ <br /> Application is hereby made to the San (omple Localte In rlealth District for Date Issued SZ ZIC <br /> and/or install the work herein described. This application is made in compliance <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Jo a permit to construct <br /> p nee with San Joaquin <br /> JOB ADDRESS/LOCATION again Local Health District. <br /> Owner's Name <br /> _ CENSUS TRACT <br /> Address � Phoned <br /> Contractor's Name J City <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL ' . <br /> /� DEEPEN /`T RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION f/- PUMP REPAIR -7 PUMP REPLACEMENT /-] <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> SEWAGE DISPOSAL FIEOOL <br /> LDEWER LINES PIT PRIVY <br /> PROPERTY LINE - PRIVATE DOMESTIC WELD, SEEPAGE PTT _ OTHER <br /> INTENDED USE TYPE OF WELL PUBLIC DOMESTIC WELL <br /> Industrial Cable Tool CONSTRUCTION SPECIFICATIONS T\ <br /> Domestic/private Dia. of Well Excavation °Q <br /> Domestic Drilled Dia. of Well Casing <br /> /Public _�- Driven Gauge of Casing <br /> Irrigation <br />^, Cathodic Protection Gravel Pack Depth of Grout Seal <br /> Disposal Rotary Type of Grout <br /> Geophysical Other _­­� Other Information <br /> Surface Seal Installed By: <br />'UMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. <br />'UMP REPLACEMENT: State Work Done <br />' 'REPAIR: / / State Work hone <br /> ES-TRUCTION OF WELL: Well Diameter <br /> Dgscri a Material and Pro dare APProxim to D pth �Q 1 <br /> c a � <br /> hereby agree to comply with all laws and regu ations of the San Joaquin Loc <br /> ad the State of California pertaining to or regulating well q construction. Within a FIFTEEN DAYS <br /> al Health District <br /> n <br /> Eter completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <br /> ELL DRILLERS REPORT of the well and notify them before Putting- the-well- in-use,... The above t a <br /> iformation is true to the•best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br />',IOR T G OUTING AND �Fj �INS�P L"rION. ECTION <br />:GNED <br /> {DRAW LE <br /> PLOT PLAN ON REVERSETSIDE <br /> AS z FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED SY <br /> DITIONAL COMMENTS. DATE �p <br /> PHASE IT GROUT TNSPECTIO <br /> SPECTTON BY DATE PHA FINAL INSPECTTO <br /> � <br /> INSPECTION BY DATE <br /> E H 1426 Rev. 74 <br />