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,rte o <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Oi%eOFFI.CE USE: ��1601 E. Hazelton Ave., Stockton, Calif. <br /> . lr <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;ZAJ <br /> � y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, ✓0-7 <br /> (Complete In Triplicate) <br /> Application is hereby =de 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 Joaquin <br /> :County Ordinance No.•,1862 and the .Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT � <br /> •r+' , I <br /> Owners Naas Phone ' <br /> Address'- City <br /> Contractor's Name License ,;F (hone <br /> TYPE OF WORK (Check); NEW WELL J DEE J67 <br /> RECONDITION~/ DESTRUCTION <br /> PUMP INSTALLATION L�' PUMP REPAIR !r]PUMP RBPLACII`IENT �f <br /> Other 17 <br /> 13IS'TANCE TO NEAREST: SEPT14C TANK SEMLINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE -- PRIVATE TI L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCT20N SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private" Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 1-- Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor 7 <br /> Type of H.P. —5 <br /> 'I <br /> E <br /> PtW REPLACEMENT: 1 11" State Work Dome <br /> PUMP -.REPAIR: L State Work Done <br /> I)ESTTRr)'MION OIC WELL: Well diameter Approximate Depth <br /> Describe Material and ProcedureA <br /> 1 <br /> I hereby agree to comply with all laws and regulations{of the San Joaquin Local Health District j <br /> and the State of California pertaining to or regulating'wel.1 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 putting thewell in.use.. The' rabove <br /> information is true to the best of• my-knowledge and belief. I WILL CALL FORA rGROUT INSPECTION <br /> PRIOR TO UT NG ANWA FANAL INSPECTION. ' <br /> SIGNED TITLE <br /> ' DRAW PWT PIAM ON REVERSE SIDE <br /> PHASE <br /> `I FOR DEP'ARTMEN'T" USE ONLY <br /> _ <br /> l 'ICATION ACCEPTED BY DATE <br /> : rIONAL COMMENTS: <br /> PHASE,-II GROUT INSPECTION P FINAL INSPECTION <br /> INSPECTION BY .__... DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />