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ell - -- <br /> FOSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '.'*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete Date Issued <br /> In Triplicate) . <br /> Application is hereby made to the San Joaquin Local. fiealth District for a permit to construct <br /> and/or install the work herein described. This application is :Wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone l6l27-2 7 <br /> Address /;� S <br /> City z--Scm4^-) <br /> Contractor's Name <br /> , <br /> ° Licensed Phone 3' ?d <br /> TYPE OF WORK (Check):,. NEW WELL /7 DEEPEN/7 RECONDITION /? DESTRUCTION /j <br /> PUMP INSTALLATION/ / PUMP REPAIR -/_7 PUMP REPLACEMENTT <br /> Other %/ <br /> DISTANCE TO NEAUSTI SEPTIC TALAR 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 /> Irrigation Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection Rotary a Type of Grout <br /> Disposal W Other Other Information <br /> Geophysical. ^`� — <br /> x _-Surface Seal Ins talled By: ; <br /> PLUMP INSTALLATION: Contractor }" <br /> - -Type of Pump ---- - r <br /> H.P. <br /> PUMP REPLACEMENT: '4 T\ �` .� <br /> . .. �/ Stata Work Done <br /> PUMP 'REPAIR: /-7 State Work Done - - <br /> DESTRUCTION OF WELL: Well Diameter <br /> T Describe Material-andProcedure + Approximate Depot <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 CALL FO A GROUT INSPECTION <br />'RIOR TO OUTING D A FINAL INSPECT ION. <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I _Ffi"EPARTMENT USE ONLY <br /> SPP ICATION ACCEPTED N� � / <br /> LDDITIONAL COMMENTS: DATE , <br /> PHASE II GROUT INSPECTION I <br /> INSPECTION BYP IFALNSPSCTIO <br /> ` DATE INSPECTION BY <br /> -- ATE p <br /> E H 1426 . Ren. 1-74 <br />