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'/,. qAN JOAQUIN LOCAL -HEALTH-DISTRICT e ,7 )C ! <br /> FOE 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 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District forra permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin { <br /> County Ordinance No. 1862 and the Rules and Regqla <br /> tions f th an Joaquin Local Health District. <br /> �- <br /> I` JOB ADDRESS/LOCATION / CENSUS TRACT <br /> f 7Wil/ Phonee-?— <br /> Owner's Name <br /> Address kL <br /> City <br /> .,_License <br /> Contractor's Nam -. - <br /> 77-7 <br /> TYPE OF WORK (Check); NEW WELL ',W DEEPEN / I RECONDITION_/_� DESTRUCTION %T <br /> PUMP INSTALLATION / -PUMP REPAIR / / PUMP REPLACEMENT I " <br /> _ Otherall 21 4z <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 SPECIFICATI94S ; <br /> Industrial Cable Tool Dia. of Well. Excavation " Qt <br /> rDomestic/private Drilled Dia.'of Well Casing <br /> ` <br /> Domestic/public Driven Gauge of Casing " "> <br /> f p <br /> Irrigation gavel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout / <br /> Disposal Other Other Information . <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of-'Pump H.P. <br /> PUMP REPLACEMENT: . /7 State Work Done _ <br /> /�...:/-4ftateTWflrk-Dane=��--•- <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth `zt . <br /> Describe Material and Procedure <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 DAXS. <br /> after completion of my work: on a new well, I will furnish the San Joaquin Local Health - <br /> WELL DRILLERS REPORT of the' well and notify them before putting the. well in use. The b ove' , <br /> information is true to the hest o£ my knowledge and belief. I WILL CALL FOR A GROUT IlSPECTION . <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> ' TITLE <br /> SIGNED <br /> D PLAN ON REVERSE SIDE T <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I ' <br /> APPLICATION 'ACCEPTED °BY DATE :.` <br /> ADDITIONAL -COMMMS: 119 <br /> L PRASE II GROUT 114SPECTIO PHA E II FINAL INSPECTION' <br /> INSPECTION BY DATE T INSPECTION BY DATE <br /> L,6 <br /> 2WE B 1426 Rev. 1-74 <br />