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FOE OFFICE USE.: SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. <br /> . tele , Stockton, Calif. <br /> Telephone :. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ` � 90 n 1 <br /> THIS 'PERMIT EXPIRES 'I YEAR FROM DATE ISSUED �(��/ <br /> (Complete In Triplicate} Date Issued ? <br /> Application is hereby made to�the San Joaquin Local Health District for apermit to construct <br /> � <br /> and/or install the work herein described. This application is made in compliance with San Jo4quin <br /> County Ordinance No. 1862 and "the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB `ADDRESS/LOCATION <br /> CENSUS TRACT i <br /> Owner's Name <br /> Phone <br /> Address ,-x- <br /> city <br /> Contractor's Name � � -- <br /> License # 4 7 Phone -76 76 <br /> TYPE"OF-WORK (Check) : NEW WELL/7 DEEPEN /`/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / <br /> Other /�/ PUMP REFLACEMENT /? <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> , SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIo <br /> INTEWELL <br /> NDED USE <br /> Industrial TYFE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> Domestic Drilled Dia. 'of Well Casing <br /> Irrigation <br /> /-public Driven Gauge of Casing <br /> � <br /> Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection 1 Rotary T <br /> _ Disposal <br /> ' i Other Type of Gout <br /> ',-Geophysical -- Other Information <br /> t Surface Seal Installed B , <br /> UMP INSTALLATION: Contractor - <br /> Type of Pump <br /> r 40 H.P. <br /> W REPLACEMENT: State Work Done - {� <br />)MP .REPAIR: r <br />--�---�� State Work Done <br /> I <br /> S-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all' laws and regulations of the San Joaquin Local Heal <br /> d the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS th District <br /> ter completion of my work on a new .well, I will furnish the San Joaquin Local Health District a , <br /> LL DRILLERS REPORT of the Well and notify them before putting the -well in use.. The above <br /> formation is true to the best of knowl ge d belief. . I WILL CALL FOR A GROUT INSPECTION <br /> COR TO GROUTING AND A FINAL .I SP OTI a <br /> GNED <br /> ` TITLE e , <br /> ( RAW PL T PLAN ON VERSE SIDE.) E <br /> kSE I OR D PARTMENT USE ONLY <br />?LICATION ACCEPTED BY <br />)ITIONAL COMMENTS: -- .DATE �2 <br /> -PHASE II GROUT INSPECTION <br /> iPECTION BY PHASE I I/FINAL INSPECTION <br /> DATE INSPECTION BY i <br /> - DATE 7� <br /> E H 1426 Rev. <br />