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SAN JOAQUIN LOCAL HEALTH DISTRICT J <br /> (204) 466--678 <br /> FOR OFFICE USE: 1601 E. Hazelton,Ave. , Stockton, Calif. /tf <br /> i� <br /> Telephone : . <br /> ii APPLICATION FOR WELL CONSTRUCTION bp, PUMP PERMIT Permit No. 7� <br /> THIS PERMIT .EXPIRES 1`YEAR, FROM DATE .ISSUED Date Issued�� l� <br /> (Complete In. Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit, to construct <br /> I and/or install the work herein described. ' This applicat on <br /> . . is made, in compliance with San Joaqui.a <br /> County Ordinance No1862 and the Rules, and. Regulations, of the, San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> Owner's Name l <br /> CENSUS TRACT <br /> , T itl Phone' ' <br /> Address <br /> C i ty A2 f <br /> s <br /> Contractor's Name <br /> { _ . License #�2 C 'Phone <br /> F TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ � <br /> RECONDITION /_/ DESTRUCTION /- <br /> PUMP/INSTALLATION /_/ PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other / / __ <br /> j DISTANCE TO NEAREST: SEPTIC TANK 2. SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD J501 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEoW PRIVATE DOMESTIC WELL 95MOY PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECI <br /> � FICATIONS <br /> ! Cable Tool Dia. of Well Excavation d <br /> Domestic/private.:ti'` Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 4C Irrigation <br /> ii Gravel Pack Depth o£ Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> E Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed BY: <br /> PUMP .INSTALLATION: Contractor <br /> Type of Pump H.P._ --- T <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:. / / State Work Done ' <br /> li <br /> DESTRUCTION OF WELL: Well Diameter } <br /> y Describe Material. and Procedure " Approximate Depth C <br /> x y <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California 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.. . The above <br /> information is true to the best of my knowledge and belief. I WILL CA <br /> PRIOR TO GROUTING D ,A FINAL INSPECTION. I, FOR A GROUT INSPECTION <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � <br /> ADDITIONAL COMMENTS; DATE /02 <br /> A-7 17 7' <br /> PHASE IT G OUT INSPECTION <br /> INSPECTION BY - — P SE /FIN INSPECTION <br /> DATE INSPECTION BY DATE <br /> E H 1426 <br /> Rev. - I-74 2A4 <br /> z <br />