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SE: <br /> FOF:oOF I � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ! U . <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone :: LS <br /> P (209) 466-6781. G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR. FROM DATE ISSUED Date Issued �3�� <br /> (Complete In.Triplicate.) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> and/or install the work herei permit <br /> County Ordinancen described. This application is made in compliancetwithnSan uJoaquin; <br /> .No. .1862 and the Rules-and Regulations of the .San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION- <br /> ?J CENSUS TRACT <br /> Owner's Name 1 <br /> r Phone <br /> Address {� <br /> s <br /> ` City <br /> Contractor's Name ll <br /> License # hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /)C•/ PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other t <br /> t <br /> DISTANCE TO NEAREST; SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYILINE - PRIVATE <br /> INTENDED USE DOMESTIC WELL PUBLIC DOMESTI WELL TYPE OF WELL 'J <br /> Industrial CUNSTKUCTION SPECIFICATIONS <br /> 1 Cable Tool Dia, of Well Excavation <br /> Domestic/private A Drilled <br /> Domestic Dia. of Well Casing <br /> /public 1 Driven Gauge of Casing <br /> Irrigation A Gravel Pack <br /> Cathodic Protection fl Rotary Type of Seal F <br /> Disposal ofGrout <br /> {I <br /> Other , Other Information j <br /> Geophysical ' Surface 5ea1 Installed II <br /> 'UMP INSTALLATION: � ) <br /> _ s^Con"tractbr 4 <br /> Type ofli.j1pump <br /> -- H.P. <br /> 'UMP REPLACEMENT: <br /> S tate Work Done k <br /> 'UMP R: { %_s4ok - -// <br /> 1. , �/ -StaIte. Wor 'Done <br /> ESTRUCTION OF,WELL: Well Diameter <br /> Describe .Material and Procedure Approximate Depth <br /> hereby agree to comply with All laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter 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 /> nformation is true to the bestlof my k wle nd belief. I WILL CALL FOR A GROUT ••INSPECTION <br /> 3IOR TO G UTING AND A FINA INSP IU <br /> IGNED <br /> °G TITLE �.�f <br /> RAW PLT PLAN ON RVERSE SIDE) <br /> SASE I FOR DEPARTMENT -USE ONLY <br /> ?PLICATION ACCEPTED BY <br /> )DITIONAL COMMENTS: DATE a Cr- <br /> PHASE II G OUT INSPECTION PHASE III/FINAL INSPECTION <br /> 4SPECTION BY DATE INSPECTION BY <br /> DATE �� <br /> E H 1426 Rev- 1-74 <br />