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s <br /> SAN JOAQUIN- LOCAL HEALTH DISTRICT w _rte' 5� <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. zl 3 3,:(/ <br /> Telephone: (209)1466-6781 <br /> APPLICATION FOR WELL\ CONSTRUCTION OR PUMP PERMIT Permit No. <br /> -SSDG� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,moi <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 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/ @N le- CENSUS TRACT <br /> )wner's Name <br /> Phone <br /> address <br /> City <br /> :ontractor's Name <br /> / License # Phone2 <br /> j� 2fa <br /> 'YPE OF WORK (Check) : NEW WELL '/V DEEPEN /_/ RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION '/ PUMP REPAIR /� PUMP REPLACEMENT J� W <br /> Other /% 7-` <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' -„” <br /> ,�,� �'oU-" 'PIT-PRIVY <br /> «�.�..._SEWAGE_DISPOSAL;_IELD�Y _ _. CESSPOOL/-SEEPAGEPIT <br /> PROPERTY LINO,'- PRIVATE DOMESTIC-_WELLA2`PUBLIC DOMESTIC WEL7, 'd�;� <br /> INTENDED USE TYPE OF WELL -I "'i CONSTRUCTION-SPECIFICATIONS <br /> Industrial Cable Toolia:Jof Well Excavatioii-' <br /> Domestic/private , DrilledDza `of We11 r,Casin <br /> Domestic/public Driven Gauge of Casing -� I g <br /> Irrigation Gravel Pack � D,epth, -of Grout Sea.IA <br /> Cathodic Protection Rotary Ty.-pe of' Gr`otit?� <br /> Disposal Other tither In?ormation <br /> Geophysical---_. ----- w <br /> Surfa¢e-_Seal-Installed.By:-- <br /> JMP INSTALLATION: Contractor _A& y <br /> Type of Pump H.P. <br /> JMP REPLACEMENT: - / / State Work Done <br /> t <br /> JMP .REPAIR: / / State -Work Done <br /> S-TRUCTION OF WELL; Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure ! � � <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ,d the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <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. IThe above <br /> .formation is true to the-best of- my knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GROUTING AND A FINAL INSPECTION <br /> GNED TITLE01 <br /> DRAW-PL' T PL ON REVS E IDE} <br /> ASE I FOR DEPAATMENT. USE ONLY <br /> PLICATION ACCEPTED BY CF. "'• DATE S �„ <br /> DITIONAL COMMENTS: �' <br /> PHA I GROUT.,INSPECTIO GASF�,AAIWT /FIVAL INSPECTIONr <br /> SPECTION BY DATE—- ",-"""INSPECTION BY DATE p <br /> E H 1426 Rev. -1-74 r,4,I-,V, <br />