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A SAN "J' OAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ? <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .7-5--5-5-5-A } <br /> y <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date -Issued <br /> ' (Complete In Triplicate) <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 :Wade in compliance with San Joaquinr <br /> County Ordinance No. 1862 andel thea Rules a d Regulations San Joaquin Local Heath District. # <br /> JOB ADDRESS/LO ONS'` r ` <br /> r CENSUS TRACT } <br /> ;Omen's Name Phone <br /> Address s <br /> 1 City . , x <br /> Contractor's Name r License19p <br /> R <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /? RECONDITION /_7 DESTRUCTION f� <br /> PUMP INSTALLATION / / PUMP REPAIR -1-7—Pump REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY. LINE - PRIVATE DOMESTT&WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION <br /> ' Industrial SPECIFICATIONS <br /> ^ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. 'of Well Casing <br /> Domestic/public Driven Gauge of Casing rr�'} <br /> Irrigation Gravel Pack Depth of Grout Seal W <br /> Cathodic Protection Rotary Type of Grout II, <br /> Disposal OtherOther Information ' ' �r { <br /> Geophysical _ Surface Seal Installed 'B d <br /> PUMP INSTALLATION: Contractor <br /> Type of, Pump <br /> H.P. . <br /> PUMP REPLACEMENT: ., State Work Don <br /> PUMP :REPAIR: /._._.f._ State Work Done - - <br /> DE9'1' UCTION OF WELL. Well Diameter <br /> Approximate Depth <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 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 putti.ng. the..well. in use... The above <br /> information is true to the.best .of my-knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTION. j <br /> a <br /> TITLE 4 - <br /> (DRAW PLOT PLAN ON REVERSE SIDE ' <br />?RASE 'I FOR DEPARTMENT USE ONLY <br /> 'PLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P GTAT .INSPECTIO . PHASE lII ]FINAL INSPECTION <br /> LNSPECTION B DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 .... <br />