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SAN JOAQUIN L .HEALTH DISTRICT <br /> FOF�;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 Date Issued Zp _ <br /> } (Complete In Triplicate) 3-7 <br /> � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui" <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Aj <br /> KY <br /> CENSUS TRACT , { <br /> Owner's Name - <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License # Phone , <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN /7 RECONDITION /? ME <br /> DESTRUCTION /� <br /> PUMP INSTALLATION '/ / PUMP REPAIR / PUMP REPLACENT f <br /> Other/ / . . . . <br /> DISTANCE TONEAREST: SEPTIC TANK <br /> . SEWER LINES. � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD EEPAGE PIT CESSPOOL/SEEPAGE PROPERTY LINE - PRZVi4 r^,.—' L... S OTHER j <br /> INTENDED USE .- PUBL-TC--;_DOME_STIC-WE-LL <br /> TYPE OF WELL' S 3 <br /> Industrial ` CONSTRUCTION SPECIFICATIONS , <br /> Cable -Tool-. _ Dia, of Well Excavation <br /> Domestic/private �""�?r31e��`. � },Dia. of Well Casing <br /> IrrDomigation <br /> ___ Driven. _,.R w ; ._. . Gauge,.of;�Casin <br /> Irrigation j <br /> Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal - <br /> . . ,Other Other Information <br /> Geophysical _.Surface Seal- Installed B <br /> ------------ <br /> PUMP 'INSTALLATION: Contractor ti ! <br /> Type of�Pump <br /> H.P. ; <br /> PUMP REPLACEMENT: . / / State Work Done _,,; T <br /> PUMP '.REPAIR: <br /> /7 State Work Done <br />)ES;TRUCTION OF .WELL: Well Diameter "� <br /> Describe Material and Procedure Approximate Depth 3 Fa,- <br /> ,,. _ <br /> t <br />[ hereby agree to comp l with all laws and regula ions of the San oaquin: Local Health District <br /> Ind the State of California pertaining to ar 'regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San"Joaquin Local Health District a <br /> DELI, DRILLERS REPORT of the well ;and notify them before putting the',.'we11. "in.use.. The above` <br /> Lnformation is true to the-best-of my..knowledge and belief. I WILL�;CAI,L FORA GROUT INSPECTION <br /> RIOR TO R UTING AND A FINAL INSPECTION. <br /> PIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r <br />'HASE I FOR $EPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY , <br /> DDITIONAL COMMENTS: / DATE <br /> PHASE II GROUT I PECTION PHASE III NAL INSPEC ON <br /> NSPECTION BY DATE INSPECTION B '- <br /> - DATE <br /> E H 1426 Rev. 1-74 <br /> r <br />